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Leads the resolution of compliance and/or privacy investigations and follows up with various parties to assure its complete resolution. Assists with management of compliance and/or privacy standards, laws, rules and regulations. Supports the management and administration of the Compliance and/or Privacy Plan. Provides advice, guidance and recommendations to minimize risk. Identifies root causes and assures plans and standards are in place including development, education and implementation of related procedures and policies. Maintains expert knowledge of compliance and/or privacy policies, procedures, issues, and trends. Handles the most complex level of investigations, inquiries, research and projects.
Leads complex audits and investigations of compliance help line calls, employee complaints, or other compliance contacts or reports; performs necessary research - often using specialized expertise, documents findings, and follows up with applicable parties through complete resolution. Collects, collates, monitors and audits data and activities to assure accuracy and to prevent, detect and correct non-compliance, illegal activities, and potential or actual fraud, waste or abuse. Works with outside consultants or external regulatory agencies performing audits as necessary. From time to time, performs investigations at the direction of legal counsel and works with legal counsel in the course of such investigation to provide guidance, recommendations and other assistance as requested by legal counsel. In such cases, the employee will report directly to legal counsel as opposed to employee's up-line leadership, and such work with legal counsel shall be confidential and protected from disclosure by the attorney client privilege and work product protection.
Exercises administrative judgment and assumes responsibility for decisions, consequences and results having an impact on people, costs, and quality of service. Leads with the development, implementation and maintenance of process improvement including departmental and/or organizational policies, procedures and methodologies - assuring compliance with laws and regulations while using accumulated data. Reviews and monitors adherence to documented plans and programs including the Code of Excellence.
Collaborates with operational and other areas in investigations (such as HR) and to implement ongoing risk identification and mitigation measures. Proactively consults with operational areas and leadership through both formal (meetings, education) and informal means. Plans, coordinates and executes effective monitoring and auditing plans to reduce non-compliance.
Maintains knowledge of complex laws and regulations impacting healthcare and health insurance delivery and reimbursement. Applies laws and regulations in daily situations while educating others through various means including formal training and annual compliance related education programs. Performs related assessments to assure compliance to laws, regulations and policies and procedures.
Maintains, updates and distributes effective, acccurate, timely reporting systems. Reports results of monitoring and auditing activities to the Compliance and Privacy Officer, Compliance. Maintains electronic records of audits, issues and investiagations. Committee and/or departmental leaders.
Manages a variety of projects related to legal/regulatory, compliance, and/or privacy. Identifies best practices and research and evaluates its implementation within our organization. Develops recommendations and action plans. Maintains attention to detail, documents details appropriately, and effectively articulates recommendations and outcomes both verbally and in writing in both small and large group forums (which may contain executives).
Required Bachelor's Degree Business, health care operations, nursing or other related area; or equivalent
Preferred Master's Degree Busines, health care operations, nursing or other related area; or equivalent
5 years of relevant experience related work experience Required
Health care operations, auditing and/or compliance Preferred
Legal or regulatory field; healthcare focus desirable Preferred
Compliance auditor, nurse auditor, or other audit function Preferred
Project management/program development and implementation Preferred
ICD-9 or ICD-10 and CPT 4 coding or medical record audit and review (facility and/or professional) Preferred
Education of clinical and non-clinical staff including Medical Staff and mid-level providers Preferred
Conducting investigations, performing interviews and summarizing results and findings Preferred
CRT-Healthcare Compliance, Certified (CHC) - HCCA Health Care Compliance Association
CRT-Professional Coder - AAPC American Academy of Professional Coders
CRT-Coding Specialist (CCS) - AHIMA American Health Information Management Association
CRT-Internal Auditor, Certified (CIA) - UNKNOWN Unknown
CRT-Fraud Examiner - UNKNOWN Unknown
CRT-IRB Professional, Certified (CIP) - UNKNOWN Unknown
CRT-Healthcare Research Compliance, Certified (CHRC) - CCB Compliance Certified Board
CRT-Healthcare Research Compliance, Certified (CHRC) - HCCA Health Care Compliance Association
SITE - Priority Health - 1239 E Beltline - Grand Rapids
PH - Compliance Medicare
Day (United States of America)
Weekly Scheduled Hours
Hours of Work
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Spectrum Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, sexual orientation, veteran status, or any other legally protected
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Who We Are
Spectrum Health is a nationally recognized not-for-profit health system, offering a full continuum of health services through our health plan, medical group and hospital group. As an integrated health system, we are able to work together across all facilities, employees and providers to create exceptional, consumer-focused interactions.
Spectrum Health is redefining what it takes to improve the health of our communities and introducing new and innovative ways for consumers to access high-quality, low-cost care so that they can connect with us for a lifetime of health.
We strive to provide one Spectrum Health experience: a consistent, high-quality, seamless health journey for consumers; no matter where, when or how they interact with us. The result is better health outcomes for the thousands of individuals, families and communities we serve.
We are the region's largest employer, with corporate offices located in Grand Rapids, Michigan. Spectrum Health Hospital Group and Spectrum Health Medical Group are consistently recognized for the exceptional care they provid