Compliance Analyst and Auditor
ProMedica`s senior care division, formerly known as HCR ManorCare, operates 335+ assisted living facilities, skilled nursing centers, memory care communities and hospice and home health care agencies. Services are provided in 26 states and currently operate under the brand names Heartland, ManorCare, ProMedica and Arden Courts. Over the next 18 months, the senior care entities will begin to rebrand to ProMedica.
Driven by its Mission to improve your health and well-being, ProMedica has been nationally recognized for its advocacy programs and efforts to address and lead in social determinants of health, champion healthy aging and cultivate innovative solutions. For more information about ProMedica senior care services, please visit www.promedicaseniorcare.org.
The Compliance Auditor/Analyst utilizes their compliance expertise to assist in the performance of compliance audits and support regulatory compliance functions at all entities across the system as a service to the Board of Trustees and all levels of management.
- Performs audits to measure compliance with regulations, policies, procedures, workflow and other applicable requirements.
- Plans, organizes, and completes auditing activities required to comply with federal payers and other compliance-related requirements.
- Evaluates compliance with governmental and other regulations regarding medical necessity, clinical documentation, etc.
- Identifies clinical risks and other risk areas along with errors in documentation, lost revenue opportunities, any overpayments, and insufficient medical record documentation, etc.
- Assesses control weaknesses, makes recommendations for improvement, and assists in the formal reporting of deficiencies identified during the audit. Assists in the development of a comprehensive audit program to address those risks.
- Prepares detailed workpapers to support completion of the audit program and any findings identified.
- Participates in pre- & post-audit meetings, providing support and recommendation for issues presented.
- Meets with auditees throughout audit process to ensure accurate understanding of area/function audited and ensure regular communication with management.
- When overpayments identified, quantify and ensure appropriate refunds completed in a timely manner.
- Educates operational stakeholders on regulations, policies, and other requirements associated with audit activity and works with stakeholders to increase and strengthen awareness and understanding.
- Complies with acceptable audit standards, plans, and schedules.
- Utilizes data analytics techniques, statistical analysis and modeling, and databases developed internally, or in conjunction with other third party vendors to detect and trend potential compliance issues.
- Provide input into the annual Compliance Workplan.
- Maintains current knowledge of laws/regulations regarding medical necessity, clinical documentation, compliance standards, auditing, and other general clinical and business matters.
- Evaluate compliance with governmental and other regulations regarding medical necessity, clinical documentation, etc. and make recommendations for improvement.
- Monitor adherence to policies, procedures, compliance standards and metrics.
- Manage and maintain updates to the Compliance plans, policies, and supporting documentation.
- Perform/assist with compliance investigations, incident response, issue resolution and documentation.
- Perform research on compliance related issues utilizing appropriate data resources. Serve as a compliance consultant and system level resource for regulatory research.
- Follow compliance project workplans, timelines and milestones.
- Track and document compliance communications (including compliance hotline calls) and activities in standardized format.
- Prepare reports, charts, statistics and other documentation as necessary to communicate compliance activities, issues and concerns to appropriate parties.
- Oversee maintenance of department compliance databases including but not limited to organization and file sequencing to support timely retrieval of documents, reports, and statistical analysis requests from internal stakeholders.
- Work directly with vendor to ensure adequacy of sanction screening process. Ensure adequate remediation of issues identified in a timely manner and keep Director, Compliance Shared Services updated as to any issues.
- Work directly with vendor to ensure effectiveness of Hotline and re-direct any non-compliance issues as needed. Ensure adequate remediation of issues identified in a timely manner and keep Director, Compliance Shared Services updated as to any issues.
- Assist in the assessment of workforce learning needs and knowledge gaps using both internal resources (i.e. audit and/or investigation results, data analysis, reported deficiencies) and industry identified high-risk areas.
- Assist in the development and implementation of compliance education for the ProMedica workforce, executive leadership and Boards of Trustees.
- Monitor progress, trends and knowledge in areas of responsibility
- Maintain current knowledge of laws/regulations regarding medical necessity, clinical documentation, compliance standards, privacy and other general clinical and business matters.
- Performs special reviews/investigations as requested.
- Performs other duties as assigned.
Job Specific Details:
- Must have a Bachelor degree and/or a minimum of four (4) years experience in relevant clinical healthcare, education/training, or regulatory compliance. Masters degree or RN preferred.
- Experience with chart review/analysis (such as utilization review, discharge planning, peer/quality reviews, etc.) preferred.
- Experience performing and analyzing regulatory research.
- Must have superior verbal and written communication skills. Must be able to understand directions, communicate, and respond to inquiries; must have excellent interpersonal skills and ability to work with people at all levels of the organization.
- Must be able to understand directions, communicate and respond to inquiries; must have excellent interpersonal skills.
- Computer proficiency required including Word, Excel, PowerPoint, and Outlook. Experience with computer-based learning required.
- Must be able to occasionally lift, move and/or carry lightweight equipment and materials. Must be able to move about facilities and between work stations.
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