This role integrates auditing with a comprehensive knowledge of denials management to evaluate current compliance programs and processes, and to assist with effecting change as necessary to maintain and improve regulatory compliance and reimbursement across service lines. This VP audits and provides recommendations to continually improve Company processes, programs and systems designed to address compliance issues related to surveys by payors, state, and federal programs, and to ensure Company staff is billing and documenting appropriately. This role oversees and collaborates on the development of compliance related data analytics, business intelligence, and other automated systems to support the organization's Corporate Compliance Plan. This VP fosters process refinement associated with reimbursement, regulatory, and other compliance initiatives within the organization. This role includes supervision of 1 direct report. Reports To: SVP of Regulatory and Compliance
Knowledge, Skills, and Experience Required Qualifications Bachelor's Degree (4) years proven experience in a compliance role in the healthcare industry – REQUIRED including ADR-denials management, CPT and ICD-10 coding
knowledge, investigations, policy and resource development. Comprehensive knowledge and understanding of federal, state and local laws/regulations. Proven leadership skills in the healthcare field. Knowledge of and ability to perform skills related to management, planning, program development and budgeting. Excellent communication and interpersonal skills. Experience presenting to students, professional audiences, internal and external senior and executive leadership both virtually and in-person is preferred. Must be able to communicate effectively with residents, responsible parties, communities, personnel and support agencies. Proficient use of personal computer and software applications used in job functions including but not limited to word processing, graphics, databases, spreadsheets, and electronic medical record systems. Working knowledge of navigating business intelligence and other data analytics platforms is preferred. Must possess a thorough knowledge of Medicare, Medicaid, private pay, and any other governmental and regulatory agencies involved in skilled nursing, senior living, PACE, outpatient, pediatrics, and home health care. Must possess a good working knowledge of Medicare/PDPM/PDGM, Managed Care, value-based care or any other reimbursement systems as it relates to industry regulation affecting the organization as well as upstream and downstream partners. Assumes responsibility for ongoing continuing education and professional development Able to adapt to changes in the work environment, can handle various demands and unexpected events. Maintain confidentially of company employee information. Attention to detail to ensure accuracy and completion. Identifies problems and resolves them in a timely manner. Prioritizes work activities to ensure all tasks are completed in a timely manner. Physical Demands Someone performing these duties should be in good physical condition and possess the capabilities, with or without reasonable accommodations.
Must be able to talk or hear and use hands to touch, handle or feel Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus Use of body mechanics and techniques for bearing weight Ability to sit for extended periods of time Ability to work on computer for extended periods of time Must be able to stoop and reach when performing daily work Work Environment This job operates remotely in the associate's home office with field travel to support compliance team initiatives as assigned. This role routinely uses standard office computer equipment such as laptops, software programs, etc.
Position Type/Expected Hours of Work This is a full-time salaried position. Some flexibility in specific work hours is allowed, and must work required hours each week to maintain full-time status.
Travel Must be willing to travel overnight as needed.
HIPAA & THE MINIMUM NECESSARY STANDARD The Employee shall maintain the confidentiality of all protected health information (PHI) whether electronic, written or oral to which he/she may be exposed either during the course of their duties or the result of an incidental disclosure. In accordance with the minimum necessary standard, the employee may only access PHI to perform the job as a Senior Vice President Quality Assurance & Compliance. The minimum necessary standard must be applied in all matters and shall continue privacy protection during non-working hours and after employment is no longer with the company.
Other Duties This job description does not list all the duties of the job. You may be asked by the supervisors or managers to perform other duties. You will be evaluated in part based upon your performance of the tasks listed in this job description.
EEO Statement HealthPRO Heritage and its subsidiaries provide equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, HealthPRO Heritage and its subsidiaries comply with applicable state and local laws governing nondiscrimination in employment in every location in which the company facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.
Principal Responsibilities and Duties Evaluate effectiveness and efficiency of business processes and internal control systems as well as ensuring Company compliance with governance regulations. Conduct data analysis related to billing and clinical documentation to support the Corporate Compliance Plan. Ensure that management, employees, and staff are in compliance with the rules and regulations of regulatory agencies and state licensure bodies, Company policies and procedures are followed, and that behavior in the organization meets established Standards of Conduct. Serve as a channel of communication to receive and direct compliance issues to appropriate resources for investigation and resolutions. Responsible for identifying, preventing, and detecting regulatory and privacy compliance issues, consistent with the Company's Compliance Plan. Act independently in his or her position so as to protect against any conflicts of interest that may arise from performing assigned duties. Facilitate ongoing compliance education and training across Company and serve as a resource partner. Audit and monitor the effectiveness of Company policies, procedures and processes. Develop and oversee policies and programs that encourage all employees across the company to seek clarification of policies, discuss compliance questions and concerns, and report suspected fraud and other improprieties without fear of retaliation. Oversee ongoing activities related to adherence to policies and procedures on privacy of, and access to, patient health information and other protected information in compliance with federal and state laws. Acts as lead for EMR-related compliance issues and collaborate with Clinical Strategies for educational training programs. Monitor survey or payor accreditation letters and leads licensure compliance requirements. Conduct in-service education, training, and orientation classes for staff and ensure timely appointments of entity / agency administrators, and oversee quarterly and annual support structures for agency administrators, including virtual meetings and reporting. Audit revenue cycle processes and ADR/denials to promote compliance with regulatory reimbursement requirements and track denials/ ADR outcomes.
