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Wellforce Provider Compliance Director in Burlington, Massachusetts

The Provider Compliance Director is responsible to design and maintain a provider compliance work plan that aligns with the specific risk categories and addresses quality, documentation, patient safety and relationships for physician practices, an Accountable Care Organization (ACO) and a clinically integrated network. The Director will oversee a multi-faceted team and continually work to create systems designed to monitor a compliant environment and provide ongoing education and training to ensure regulatory guidelines are provided timely. The position calls for a dynamic and creative thinker that can formulate an analytics-driven approach to compliance related business problems in a visual and persuasive matter. This position requires a motivated individual with a technical background as well as strong organizational, time management, critical thinking and problem-solving skills to manage a variety of projects in a fast-paced environment.

The intent of this job description is to provide a summary of the major duties and responsibilities of this position and shall not be considered as a detailed description of all the work requirements that may be inherent in the position.

Responsibilities

  • Recommends efficient work processes with emphasis on automation and maximizing the use of Epic electronic health record and other approved auditing/coding software. Continually assess coding and compliance software that will improve coding effectiveness and efficiency.

  • Develops and coordinates a multifaceted educational and training program that focuses on the elements of the Compliance Program and assists with developing other educational programs, as well as working to ensure that all appropriate business partners, employees and management are knowledgeable of and comply with, pertinent federal and state standards.

  • Prepares and/or presents performance indicator reports to management, providers and other stakeholders.

  • Serves as chair of a compliance subcommittee, as assigned. The compliance subcommittee meets regularly and has responsibility for and oversight of the reporting, monitoring, and tracking of provider identified compliance issues and subsequent corrective action plans.

  • Designs and maintains provider, ACO and clinically integrated compliance work plans that align with the specific risk categories and addresses quality, documentation, patient safety and relationships with providers and other stakeholders.

  • Investigates, coordinates and resolves compliance hotline incidents.

  • Foster relationships with hospitals, network and non-network physicians and community agencies.

  • Updates compliance knowledge, as requirements change, by tracking and researching emerging professional coding and billing practices.

  • Maintains current knowledge of applicable federal and state laws and accreditation standards.

  • Provides compliance guidance on relevant patient grievances and complaints for the provider or community practices.

    Experience

  • Bachelor’s degree in accounting, finance, or Health Information Management, are preferred but will consider extensive (10+ years) coding and compliance experience with demonstrated progressive roles and responsibility.

  • Coding Certification – CPC or CCS-P required.

  • CHC is required or obtained within 24 months of hire date.

  • Supervises and evaluates staff and external consultants (as needed).

  • Skilled in conducting audit trails and analyzing data, evaluating information and drawing logical conclusions.

  • Responsible to understand the Office of Inspector General’s (OIG) seven elements of an effective compliance program.

  • Timely response to regulatory requests for information (e.g., OIG, Office of Civil Rights, Department of Health, etc.).

  • Proficient in analytics such as Epic and other relevant data software sources used to perform job duties.

  • Works to develop methods, tools and/or procedures to increase department efficiency.

  • Must possess ability to function efficiently and effectively with co-workers and other stakeholders.

  • Must possess initiative, the ability to work independently, and strong analytical, critical thinking and problem-solving skills.

  • Produces accurate and concise work products that require no more than minor revisions.

  • Prepares reports and dashboards, as requested and scheduled.

  • Manages multiple tasks simultaneously ensuring timely execution in a fast-paced environment.

  • Maintains confidentiality of all materials handled within the organization as well as the proper release of information.

  • Assists with creating or updating audit steps to include in the compliance work plans.

  • Demonstrates the ability to work effectively within multidisciplinary teams.

  • Demonstrates financial responsibility and accountability through the effective and efficient use of resources in daily procedures, processes and practices.

  • Complies with organizational policies regarding attendance and dress code.

  • Attends meetings, trainings and in-services as required.

  • Day shift Monday through Friday and any other hours as needed.

  • Other related duties as assigned.

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