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Director Regulatory and Reimbursement

Job ID: 105098 Date posted: September 24, 2020

  • Sharp HealthCare
  • Corporate Compliance
  • Executive Jobs
  • Day Job
  • Full-Time

Responsibilities

Director, Regulatory & Reimbursement – Corporate Compliance

Sharp System Services

Summary:

The Director, Regulatory & Reimbursement’s primary purpose is to assist the Vice President (VP) Corporate Compliance with the oversight and maintenance of a high-quality, effective, best practices revenue cycle/integrity compliance program to prevent and detect violations of law and other misconduct and to promote ethical practices and a commitment to compliance with applicable federal, California, and local laws, rules, regulations, and internal policies and procedures.

The position plays a key role in oversight of Sharp HealthCare’s Compliance Program by directing and overseeing Sharp’s regulatory and reimbursement compliance function and maintaining Sharp HealthCare’s system-wide view of revenue cycle/integrity compliance across all Sharp entities interacting with leadership in HIM, Revenue Integrity/Cycle, Utilization Review and Case Management functions.

Skills and Qualifications:

  • Minimum of ten (10) years of experience in a health care revenue cycle compliance or related field.

  • Experience working with Healthcare Provider Corporate Compliance initiatives and environment is required.

  • Minimum of five (5) years of experience in supervisory, project management and/or managerial responsibilities required.

  • Experience working in a complex health system with Health Plan Corporate Compliance and/or Medical Groups is preferred.

Education:

  • Bachelor’s degree in an applicable field such as, Business Administration with emphasis in finance and accounting, Nursing, Law, Health Information Management or Health Care Administration required.

  • Masters in health care related field preferred.

Licensure:

  • CHC – Certified in Healthcare Compliance, Certified Coding Specialist, (CCS) or a RHIA credential through the American Health Information Management Association (AHIMA) is required.

  • Project Management Professional (PMP) certification or any other healthcare compliance related certification is preferred.


Key Responsibilities (partial listing):

 

The Compliance Director, Regulatory and Reimbursement is accountable for:

 

•Preparing the quarterly and annual reporting of Sharp HealthCare Revenue Cycle Compliance Work Plan, including utilization review and case management, in conjunction with the Vice President/Corporate Compliance and Regulatory Compliance Director

•Spearheading best practices for revenue cycle compliance and integrity based on the latest regulatory guidance, and is responsible for the training and education on the prevention of coding and billing compliance violations, the promotion of ethical practices, and a commitment to compliance with the Federal and state laws and regulations.

•Developing, and overseeing the execution of all aspects of the Sharp Coding and Billing Compliance Program including utilization review and case management. Whereby principal duties include the establishment and oversight of key activities related to the Coding and Billing Compliance Program operations in accordance with the relevant with federal, state and local rules and regulations. This includes:

•Overseeing and assisting with performance of documentation, coding validation reviews, utilization review and case management including physician coding reviews for compliance with Federal, state and local rules and regulations. 

•Directing the Regulatory and Reimbursement Team to identify, mitigate and resolve risk areas, compliance issues/concerns and overseeing the compliance review of patient charts for accuracy of coding, billing, and medical record documentation against the relevant Federal, state and local rules and regulations.

•Leading the development of educational and resource materials for employee compliance for clinical documentation, coding and billing compliance, utilization review and case management and is responsible for internal communication tools such as the regulatory and reimbursement compliance SharePoint site and management newsletters or compliance bulletins related to revenue cycle compliance.

•Overseeing and directing the compliance training sessions for staff and physicians of Sharp HealthCare.

•Working closely with Sharp Revenue Integrity/Cycle, HIM, Clinical, Utilization Review and Case Management to support the design of processes to meet regulatory requirements, and implementing ongoing risk assessments and monitoring techniques.

•Preparing written reports to document revenue cycle, coding and billing compliance risk assessments, observations, corrective actions and timeliness, and specific recommendations to improve internal controls and mitigate risks.

•Leading the development and implementation strategies to identify future legislation, rules, regulations, or documentation standards impacting providers related to revenue cycle compliance; Formulating strategic initiatives to ensure that processes are effectively designed and all providers and key stakeholders receive appropriate education and training related to future coding and billing compliance requirements; and supporting Sharp management, personnel and health care providers in their efforts to comply with all applicable laws, regulations, and policies governing third party reimbursement activities.

•Providing direct support to the CC Vice President toward effecting ongoing operation/enhancement of CC coding, billing, clinical record documentation, clinical trials, reimbursement, legal and financial imperatives/projects and processes that are designed to maximize quality/integrity/cost safety/security containment for Sharp HealthCare patients, staff, physicians and leadership.

•Managing, supervising, directing, monitoring, and assuring the quality of work performed by the Corporate Compliance Regulatory and Reimbursement Manager, Analysts and Compliance Clinical Analyst. Work with CC Vice President for the development of staff departmental guidelines and procedures.  Hire, coach, lead, mentor, and offer guidance in the growth and development of the Regulatory and Reimbursement Team.Ensures that the Regulatory and Reimbursement Team adheres to all Sharp HealthCare policies and procedures and coaches and counsels as appropriate.  Assures that employee performance issues are addressed in a timely manner.  Completion of annual performance reviews for the Regulatory and Reimbursement Team in a timely manner. Accountable for managing and adherence to operating budget for the Regulatory and Reimbursement Team.

•Providing leadership and strategic recommendations in the ongoing development, efficiency and organization of the Sharp HealthCare's strategic coding, billing and reimbursement initiatives driven by Corporate Compliance. Provides direct support to the CC Vice President toward effecting ongoing operation/enhancement of CC Operations, focusing on imperatives/projects and processes that are designed to provide the maximum quality/integrity/reimbursement for Sharp HealthCare patients, staff, physicians and/or leadership. Provides leadership and resource for the Corporate Compliance Department, as well as presentation expertise for internal and external target audiences. Demonstrates a solid commitment to the delivery of high quality; conducts business with integrity and honesty.

 

Compensation and Benefits:

The position provides a very competitive compensation, including opportunity to participate in a management bonus incentive program along with a generous benefit package.

 

 

Please note: Unsolicited resumes from employment agencies or other third parties will not be considered.

 

“Sharp HealthCare is an Equal Opportunity/Affirmative Action Employer, we celebrate our employees’ differences.  All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, disability, gender, gender identity, transgender status, sexual orientation, protected veteran status, among other things, or status as a qualified individual with disability. Different makes us better.”


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“After nearly 10 years of working here, it's still one of the hardest jobs I've ever loved. If you find a niche here, you'll be working with some of the smartest in the industry. This is where they'll respect you for thinking outside the box and kindness matters. They expect consistency and hard work, but pay you well to do it.”

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