Lead Compliance & Quality Audit

Summary/Objective
Under limited supervision, Omega’s Lead Compliance and Quality Audit Manager performs audits of inpatient and outpatient medical records for coding accuracy and medical record documentation as it impacts the accuracy of ICD-10-CM, ICD-10-PCS codes driving the MS-DRG assignment and ICD - 10 CM and CPT-4/HCPCS codes driving the APC assignment. Lead Compliance and Quality Audit Manager must be able to identify Physician query opportunities, assess the accuracy of POA, discharge disposition and modifier assignments. Lead Compliance and Quality Audit Manager performs data collection for quality and statistical purposes and reports the finding the Client. The Lead Compliance and Quality Audit Manager is the first line of support for the HIM QA Managers, assists in coaching and developing staff members as necessary and completes special projects as assigned. 

Essential Job Functions

• Review inpatient and outpatient medical records for accuracy of coding and data quality. Elements to be included in reviews can include:

  Inpatient/Observation Cases

  • All diagnosis and procedure assigned ICD-10-CM and ICD- 10 PCS codes

  • Discharge disposition assigned

  • Assigned Present on Admission (POA) indicators 

  • APR, SOI, and ROM assignment for inpatient cases

  • All diagnosis and procedure assigned ICD-10-CM and ICD-10 PCS codes

  • All CPT assigned codes

  • Modifier use and assignment

  • APC assignment

  Outpatient Cases (ER, SDS, Ancillary)

Professional Services

• All diagnosis codes

• All CPT assigned codes

• All E&M leveling codes

• Maintain auditing productivity based on Client and Omega agreed upon requirements. 

• Complete Quality Review reports timely and submits Omega (subsequently to Client) for review.

• Work with the Omega Compliance Team to develop and provide coder/coding training and education sessions, group, or one-on-one sessions, as needed, based on results of the Coding Quality Reviews.

• Provide support in the absence of the Manager, CQA Services, demonstrating aptitude to temporarily perform all duties of the Manager, CQA Services.

• Provide support for special assignments which may include but are not limited to phone assessments, CodeONe, strategic initiatives and cross functional teams.

• Utilize all available official references to perform reviews: to include but not limited to International Classification of Diseases, 9th Edition, Clinical Modification (ICD-9-CM), the Current Procedural Terminology (CPT-4) Official Coding Guidelines, Coding Clinic, CPT Assistant, CMS guidelines, etc. 

• Communicate effectively with supporting staff and Omega point-of-contact(s). Provides information regarding work progress, actions, and issues in a timely and effective manner. 

• Must be skilled in Microsoft Excel.

• Perform duties in compliance with Company’s policies and procedures, including but not limited to those related to HIPAA and compliance.

Key Success Indicators/Attributes

• Extensive knowledge of ICD-10-CM, ICD -10 PCS and CPT-4 coding and MS-DRG and APR-DRG assignment. 

• Extensive knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation, coding, and billing in addition to those that are state-specific.

• Knowledge of documentation requirements to support coding and POA assignment is required.

• Extensive knowledge of medical terminology, anatomy, and physiology

• Demonstrate ability to self-motivate, set goals, and meet deadlines.

• Demonstrate professional demeanor and strong interpersonal skills. 

• Demonstrate excellent presentation, verbal, and written communication skills.

• Demonstrate excellent analytical, critical thinking and problem-solving skills. 

• Skill in operating a personal computer and utilizing a variety of software applications.

• Knowledge of coding convention and rules established by the American Medical Association (AMA), the American Hospital Association (AHA) and the Center for Medicare and Medicaid (CMS), for assignment of diagnostic and surgical procedural codes.

• Knowledge of JCAHO, coding compliance and HIPAA-HITECH standards affecting medical records and the impact on reimbursement and accreditation.

Supervisory Responsibility

Yes, supervises a team of Auditors (usually 15 to 20 Auditors).

Work Environment

This job operates in a remote home office environment. This role routinely uses standard office equipment such as computers and phones.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; and talk or hear. The employee must occasionally lift or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, peripheral vision, depth perception and the ability to adjust focus.

Position Type/Expected Hours of Work

This is a full-time position. Days and hours of work are generally Monday through Friday, 8:00 a.m. to 5 p.m. This position occasionally requires long hours and weekend work.

Travel

Minimal travel required; up to 5%

Required Education and Experience

• AHIMA Approved ICD-10 CM/PCS Trainer

• Minimum of successful completion of an AHIMA-approved Coding Certificate Program; 

• Associate’s degree or equivalent training acquired through five years of progressive on-the-job experience.

• Must have at least five years of HIM experience, preferably as an Auditor.

Preferred Education and Experience

None

Additional Eligibility Qualifications

Must have CCS, CPC, CPC-P, CPC-H, RHIA or RHIT

Security Access Requirements

In addition to the specific security access required by the employee’s client engagement, the employee will have access to the Omega systems set forth in the “Standard Field Employee”” profile.

Equal Employment Opportunity

Omega Healthcare is an Equal Employment Opportunity employer. All qualified applicants will receive consideration for employment without regard to their race, color, religion, national origin, gender, age, sexual orientation, gender identity or expression, marital status, mental or physical disability, protected veteran status, and genetic information, or any other basis protected by applicable law. Omega Healthcare also prohibits harassment of applicants or employees based on any of these protected categories.

Omega Healthcare makes reasonable accommodations when needed for applicants and candidates with disabilities or religious observances. If reasonable accommodation is needed to participate in the job application, interview, or any other part of the hiring process, please contact Human Resources at employeerelationsus@omegahms.com.

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job.  Duties, responsibilities, and activities may change at any time with or without notice. Employee may perform other duties as assigned.