The Senior Compliance Professional ensures compliance with governmental requirements, specifically risk adjustment coding and medical record document requirements. This role acts as the second line of defense by providing oversight and monitoring of CenterWell Primary Care Organization provider clinics including serving as a compliance subject matter expert for revenue cycle management, including risk adjustment and fee for service coding, medical record documentation and value-based care programs. The Senior Compliance Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

Responsibilities

The Senior Compliance Professional develops and implements compliance policies and procedures. Researches compliance issues and recommends changes that assure compliance with contract obligations. Maintains relationships with government agencies. Coordinates site visits for regulators, coordinates implementation and compliance with corrective action plans, as needed. Begins to influence department’s strategy. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction. Exercises considerable latitude in determining objectives and approaches to assignments.

The Senior Compliance Professional develops and implements Compliance policies and procedures, research issues and recommends changes that assure compliance with payer contract obligations. Maintains relationships with government agencies and coordinates site visits for regulators as needed. Participates in all phases of the audit process including evaluating control design and adequacy, testing to ensure adherence with established policies and internal controls, and communicating issues and recommendations to management. Coordinates implementation and compliance with corrective action plans. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Required Qualifications

• Bachelor's degree
• 5 or more years of healthcare revenue cycle management experience may suffice (to include, billing, coding, collections for Medicare and Medicaid related claims)
• Experience with Auditing and monitoring of healthcare records
• 3+ years experience with claims, provider documentation and/or coding
• Some technical or data driven analysis experience
• Ability to manage multiple or competing priorities and meet deadlines
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences
• Effective verbal and written communication skills
• Strong attention to detail
• Ability to articulate findings and impacts
• Knowledge/understanding of laws and regulations governed by the Department of Insurance and CMS

Preferred Qualifications

• Compliance regulations knowledge and compliance auditing experience
• Ability to analyze large data sets
• Knowledge of healthcare compliance, mainly primary care and risk adjustment, pharmacy knowledge a plus
• Six Sigma or Lean Certified
• Graduate degree, MBA or Healthcare focus a plus
• Certified Coder (CPC, CRC, and/or CMC)
• Experience with metrics and reporting

Additional Information

Scheduled Weekly Hours

40