Position Summary
The Clinical Documentation Compliance Auditor manages comprehensive medical record documentation preparedness for demonstrating compliance with regulatory, accreditation, and payor requirements; produces and maintains cumulative documentation compliance program activity records and analytical reports; tracks and trends documentation compliance program activities; ensures immediate availability of program integrity component documentation reviews; produces and manages quick reference guides to promote organizational awareness of documentation requirements; provides recommendations for improvement based on identified issues; and supports organizational accountability by producing and managing timelines to ensure issue closure and response deadlines are met.
Primary Duties and Responsibilities
- Maintain awareness of CMS Medicaid Integrity Program and “Documentation Matters” guidelines for behavioral healthcare practitioners
- Audit medical records, with a focus on meeting key regulatory and payor requirements, such as meeting required number of hours of services, completion of required sessions, and accurate data entry to assure appropriate billing.
- Organize and present audit data in a quantitative and meaningful way to support data analysis and decision making.
- As directed by the Chief Compliance Officer, investigate and maintain investigation documentation for, fraud/waste/abuse allegations related to medical record documentation.
- Research payor and regulatory medical record documentation requirements related to services offered.
- Develop educational materials and quick reference guides to promote organizational awareness of documentation requirements.
- When directed by the VP, Clinical Compliance and Quality Management, analyze workflows, and provide corrective action recommendations based on audit results.
- Provide project management support for corrective action plans, with a focus on supporting organizational accountability by producing and managing timelines to ensure issue closure and response deadlines are met.
- Understand the flow of information across software platforms as they relate to medical record documentation and associated billing, particularly the flow of information between electronic medical record and billing software.
- Annually identify specific needs for self-development and implement a plan to achieve professional growth.
- Participate in other projects as assigned and completes tasks within requested timeframes.
- Participates in periodic clinical compliance and quality program effectiveness evaluations.
Job Qualifications and Requirements
Education:
- Bachelor’s degree in social work, psychology, counseling, healthcare administration, or related field required.
- Master’s Degree in social work, psychology, counseling, healthcare administration, or related field preferred.
- Clinical/Mental Health licensure preferred (e.g., LMSW, LCSW, LPC, LMFT).
Experience:
- Minimum of four (4) years of progressively responsible and directly related experience. Experience in 24-hour non-hospital mental health and/or substance use disorder treatment settings strongly preferred.
- Experience in a utilization review or billing role preferred.
Knowledge/Skills:
- Ability to communicate effectively, demonstrating excellent verbal and written communication skills.
- Ability to plan, organize, and prioritize multiple tasks and work independently to meet deadlines and exercise sound professional judgment.
- Knowledge and general understanding of federal, state, payor, and accrediting body documentation compliance program requirements for behavioral healthcare organizations.
- Strong understanding of staff and client stakeholder requirements as they related to client medical records.
- Strong understanding of revenue cycle management stakeholder requirements, including connection between clinical workflow, utilization review workflows, and revenue cycle management workflows.
- Ability to evaluate the degree to which documentation matches payor clinical quality expectations, including appropriateness of interventions, ASAM application, LOCUS application, and use of evidence-based practice.
- Working understanding of facility operations and basic workflows.
- Ability to work effectively with individuals at all levels and with varying backgrounds both within and outside the organization
- Knowledge of and ability to use a personal computer and standard business software applications for word processing, spreadsheets, databases, presentations, and e-mail.
- Knowledge of and ability to use department-specific and enterprise computerized information systems to support compliance functions.