Senior Coding Compliance Specialist, ACO - REMOTE

About Sound:

Headquartered in Tacoma, WA, Sound Physicians is a physician-founded and led, national, multi-specialty medical group made up of more than 1,000 business colleagues and 4,000 physicians, APPs, CRNAs, and nurses practicing in 400-plus hospitals across 45 states. Founded in 2001, and with specialties in emergency and hospital medicine, critical care, anesthesia, and telemedicine, Sound has a reputation for innovating and leading through an ever-changing healthcare landscape — with patients at the center of the universe.

Sound Physicians offers a competitive benefits package inclusive of the items below, and more:

• Medical insurance, Dental insurance, and Vision insurance
• Health care and dependent care flexible spending account
• 401(k) retirement savings plan with a company match
• Paid time off (PTO) begins accruing immediately upon start date at a rate of 15 days per year, in accordance with Sound's PTO policy
• Ten company-paid holidays per year  

About the Role:

Under the direction of the Chief Compliance & Privacy Officer and the Director of Compliance & Audit, the ACO Compliance Specialist will coordinate and support compliance functions and activities in support of enabling Sound Long-Term Care Management Accountable Care Organization (SLTCM-ACO) providers to comply with all applicable billing and privacy compliance regulations.

The ACO Compliance Specialist is responsible for conducting retrospective compliance reviews of documentation supporting codes assigned by practitioners to ensure accuracy in billing and compliance with Federal, State, payer, and institutional requirements. The ACO Compliance Specialist serves as the compliance lead and works cooperatively with SLTCM-ACO leadership and clinical leadership at ACO sites. Through the review process, the ACO Compliance Specialist also identifies opportunities to improve coding practices and related business processes or issues needing further review, assessment, and follow-up. The ACO Compliance Specialist provides individual and group coding and documentation training and works collaboratively with the Compliance Department and ACO Leadership to develop coding and documentation training materials and establishment of training plans for the practitioners in partnership with SLTCM-ACO.

The ACO Compliance Specialist contributes to compliance program development by maintaining data for program reports, participating in the development and/or delivery of educational and outreach materials, and maintaining program records. The ACO Compliance Specialist will maintain current knowledge of applicable laws and regulations and may contribute to the unit’s risk assessments and risk mitigation strategies.

The ACO Compliance Specialist functions as part of a unit team to accomplish unit goals and works cooperatively with other compliance staff and entity staff as needed to resolve shared issues and concerns. In addition, he or she may participate in committees, workgroups, or process improvement projects as assigned.

The Details: This role is remote, work from home, but may occasionally require site visits.

In this role, you will be responsible for:

• Performing complex coding and documentation compliance reviews of SLTCM-ACO partners in the Nursing Facility, Post-Acute Care, and Telemedicine settings using applicable rules, regulations, and coding conventions for billing to determine the accuracy of coded and billed services, including APP services where applicable
• Conducting special reviews based on risk assessment activities, external or government audits, or in response to an inquiry or identified potential concern. Assessing data and formulating recommendations to mitigate or resolve identified issues
• Obtaining, organizing, and formatting billing and other data captured through the review process. Preparing clear, concise written reports related to the special review findings for internal and external reporting purposes, calculating refunds using a variety of methods, including extrapolation
• Performing follow-up reviews to determine the status of implemented recommendations, efficacy of coding and documentation education as well as compliance with regulatory guidelines and internal policies
• Reporting and reviewing audit findings with Chief Medical Officer, Value Based Care for SLTCM-ACO and the Chief Compliance & Privacy Officer on a regular basis to identify trends, issues, and potential risk areas. Informing management of issues or concerns identified with coding practices of faculty or coding staff
• Serving as a knowledge resource for coding and documentation standards. Responding to billing and coding questions related to review findings from ACO Partners and staff
• Maintaining effective and collaborative relationships with providers, administrative and revenue support staff
• Maintaining awareness of healthcare billing processes implemented in the organization
• Maintaining awareness of current compliance issues and coding initiatives through self-study and participation in professional educational conferences. Maintaining coding expertise in assigned areas
• Supporting institutional compliance efforts by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting concerns, and adhering to applicable laws, regulations and institutional policies and procedures
• Performing other duties, as assigned

• Assisting Director of Compliance & Audit with establishing a prospective audit plan for the ACO sites and providers
• Assisting the Coding Compliance Supervisor with an initial assessment of all sites/providers participating in the ACO
• Working directly with ACO Leadership to ensure compliance for providers under the ACO umbrella
• Being responsible for auditing records for providers in the ACO who provide the following types of services: SNF, NF, Behavioral Health, Wound Care, Infectious Disease, Annual Wellness Visits, Chronic Care Management visits, and Telemedicine
• Creating and providing education to site leadership and directly to providers around CPT coding and billing related to the ACO
• Communicating directly with site leadership, ACO leadership, and ACO participating providers to answer questions related to audited encounters and CPT coding and billing for ACO services
• Adhering to all company policies and procedures
• Always representing Sound Physicians and SLTCM-ACO confidentially and professionally
• Immediately reporting regulatory compliance issues, or concerns to the Chief Compliance & Privacy Officer
• Maintaining strict confidentiality of all information obtained from any source in accordance with privacy and disclosure laws and Sound Physicians and SLTCM-ACO policies
• Consistently demonstrating integrity, initiative, and team-building support

What we are looking for:

A successful candidate will have a demonstrated track record of a combination of these values, knowledge, and experience:

Values:

• Work Ethic – Dedication to getting the job done well and on time, regardless of circumstances, a can-do attitude
• Communication: The ability to speak, write, and listen clearly and consistently
• Relationship Building and Maintenance: The ability to create and nourish healthy, strong relationships, as the face of Sound
• Teamwork: Demonstrates the ability to pull people together into highly effective teams along with ability to work in a highly matrixed organization
• Critical Thinking: Demonstrates the ability to be proactive, anticipate needs; ability to make good decisions with incomplete, ambiguous information
• Adaptability: Demonstrates flexibility and a willingness to change as circumstances evolve and be coachable
• Resourceful: Proactive willingness to utilize available information and tools to figure things out, not afraid to ask questions when necessary
• Commitment: Demonstrates a dedication to the job, project, organization, customer/clients, and co-workers
• Strategic Thinker: Demonstrates the ability to look at the big picture and proactively develop a plan of action
• Self-Motivated: Proactively jumps in to start a task or project with limited direction; asks to take on more responsibility and what is next
• Collaborative: Demonstrates the ability to work well with others to accomplish a goal and get the work done; takes opinions of others into consideration; includes others in the decision-making process

Knowledge:

• Bachelor’s degree in a health sciences discipline, business, or related field desired or equivalent experience
• A current coding credential from AHIMA and/or AAPC
• Extensive knowledge of 2023 E/M Documentation Guidelines ICD-10 CM, CPT and HCPCS coding principles and guidelines
• Knowledge of federal and state regulations related to documentation, coding, and billing
• Knowledge of CMS, Medicaid, and Medicare Advantage
• Excellent oral and interpersonal communication skills, with the ability to convey a positive and professional image in person, and to interact effectively with diverse personalities and backgrounds
• Must be highly organized, detail oriented, and able to manage multiple competing priorities with a high degree of speed and accuracy
• Proficiency with Windows-based software and Microsoft Office Suite products in a network environment

Experience:

• Minimum of five years' experience with Nursing Facility, Telemedicine, and Post-Acute Care billing, coding operations, and compliance
• Ability to evaluate current workflows and processes with a critical eye and develop proposals for improvement
• Ability to interpret physicians’ documentation and identify/extract billable services from medical records
• Successful experience working both independently and as a team
• Demonstrated ability to establish positive and courteous working relationships, effectively manage competing priorities, apply critical thinking skills, and accurately complete highly detailed work

Sound Physicians is an Equal Employment Opportunity (EEO) employer and is committed to diversity, equity, and inclusion at the bedside and in our workforce. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, gender identity, sexual orientation, age, marital status, veteran status, disability status, or any other characteristic protected by federal, state, or local laws.

This job description reflects the present requirements of the position.  As duties and responsibilities change and develop, the job description will be reviewed and subject to amendment.