At Sevita, we believe that everyone deserves to live well. For more than 50 years, our team members have provided home and community-based health care for adults, children, and their families across the United States. Our extraordinary team offers innovative, quality services and support that lead to growth and new opportunities for the people we serve and for our employees.

Summary

The Clinical Compliance Auditor is responsible for collaborating with Operations and Revenue Cycle in auditing/monitoring compliance requirements across all Company business units and service lines. Ensures that existing clinical audit standards and procedures are best practice according to legal and regulatory requirements; payer requirements and expectations; and external and internal standards. Executes clinical audits with the aim of identifying gaps and recommend changes to clinical practices to ensure that optimum care is delivered to the individuals we serve and support. Collaborates with Ethics and Compliance Officers to contribute to projects related to the Compliance Audit, Self-Monitoring, Data Mining and Risk Assessment programs. Supports the leadership of the Company and the Chief Compliance Officer.

This position is remote and can be performed from anywhere in the U.S. There is some travel required.

Responsibilities:

• Acts as an accessible, visible and available subject matter expert to the business as it relates to audits.

• Establishes a compliance culture as a strategic, competitive advantage with each audit performed.

• Evaluates the areas of risk to be addressed by each audit. Interprets the relative significance of issues needing resolution; escalates at appropriate time.

• Assists in the development of the annual Compliance Audit Plan and Company Compliance Plan.

• Conducts scheduled and non-scheduled compliance audits according to the audit plan while testing compliance with pertinent billing and coding requirements; internal policies and procedures; and external accreditation standards. Reviews quality, medical, and clinical processes for adherence with company, industry, accreditation, state, and federal guidelines.

• Coordinates with clinical operations and the revenue cycle teams to ensure accounts audited reflect proper documentation, charge capture, coding, billing and payment.

• Contributes to the identification and reduction of the Company’s coding compliance risks, billing inaccuracies, and/or denials by coordinating independent reviews and assessments of the organization's professional coding and billing transactions, processes, and internal controls for coding completeness and accuracy.

• Coordinates and executes pre- and post-payment audits of medical records and associated clinical documentation to ensure proper charge capture and billing in accordance with standard state, federal, and internal reimbursement policies, principles, and mandates. Reviews and interprets operational and clinical information from a variety of sources such as individual service records and determines whether clinical guidelines are being followed. Performs mock audits to support continual audit readiness.

• Performs risk assessments to identify compliance and non-compliance concerns.

• Supports the Compliance Audit team during audits; helps to support management discussions regarding identified issues affecting the business and operations.

• Reviews compliance with existing policies and procedures by performing the required audit steps and reviewing internal controls. Assists with the day-to-day compliance and auditing including chart reviews, managing, and analyzing compliance data and serves as a resource to the Compliance Department.

• Prepares audit reports based on audit findings derived from and supported by the audit work papers.

• Collaborates with the Compliance Audit team to provide recommendations requiring management responses to address identified observations or findings

• Utilizes the 5 C’s of audits: criteria, condition, cause, consequence, and corrective action

• Participates in audit exit meetings to review and communicate audit report findings.

• Reviews management responses to determine if recommendations have been satisfactorily addressed. Addresses responses requiring further clarification.

• Develops and maintains current knowledge of laws, regulations, and market changes that impact all aspects of the Company, including, but not limited to, Stark Law, Anti-Kickback Statute, Patient Inducement Statute, Health Insurance Portability and Accountability Act, relevant Office of Inspector General (OIG) Model Guidance and applicable Advisory Opinions.

• Supports review of new business activities and programs as an audit subject matter expert.

• Participates in activities related to exclusion screening, as it pertains to new hires, current employees, vendors and providers. Partners to understand and participate in resolution pathways.

• Ensures necessary follow-up takes place to resolve open items, ensuring controls are in place to successfully mitigate business and regulatory compliance risks.

• Completes special projects and reports as needed by the Compliance Department.

• Performs other related duties and activities as required.

Qualifications:

• Nursing license and/or other clinical degree preferred

• 1-3 years' experience in healthcare and/or compliance or an advanced degree without experience.

• Professional certification (CIA/CHC) preferred.

• Knowledge of statistical auditing methods and Medicaid reimbursement preferred.

• Strong ability to communicate orally and in writing to individuals and groups from varied disciplines and levels of management.

• Strong communication, interpersonal and presentation skills, working with both internal and external individuals and entities

• Strong ability to self-motivate.

• Excellent analytical, problem solving, project management, leadership and team building.

• Strong computer skills with proficiency in Microsoft Office

• Maintains discretion and safeguards confidential information

• Travel as needed, approx. >25%.

Why Join Us?

• Full compensation/benefits package for employees working over 30 hours/week

• 401(k) with company match

• Paid time off and holiday pay

• Enjoy complex work that makes a difference in the lives of those we serve

• Career development and advancement opportunities across a nationwide network

We have meaningful work for you – come join our team – Apply Today!

Sevita is a leading provider of home and community-based specialized health care. We believe that everyone deserves to live a full, more independent life. We provide people with quality services and individualized supports that lead to growth and independence, regardless of the physical, intellectual, or behavioral challenges they face. We’ve made this our mission for more than 50 years.

Sevita is committed to providing equal opportunities to all employees and applicants for employment. We are committed to creating an inclusive and diverse workplace that values and respects the unique talents, experiences, and perspectives of our employees and the people we serve.

As an equal opportunity employer, we do not discriminate on the basis of race, color, religion, sex, national origin, age, disability, genetic information, sexual orientation, pregnancy, gender identity or any other characteristic protected by law.