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Compliance Specialist

PRMO Full Time Durham, North Carolina
Requisition Number: 236681

Duke Health strongly recommends getting up-to-date vaccinations against COVID-19, especially for those with conditions that place them at higher risk. However, COVID-19 vaccination is no longer a requirement for team members at Duke Health.

PRMO Established in 2001, Patient Revenue Management Organization (PRMO) is a fully integrated, centralized revenue cycle organization supporting all of Duke Health, including Duke University Hospital, Duke Regional Hospital, Duke Raleigh Hospital, the Private Diagnostic Clinic, and Duke Primary Care. The PRMO focuses on streamlining the revenue cycle through enhanced management of scheduling, registration, coding, HIM operations, billing, collections, cash management, and customer service. The Mission of the PRMO is delivering quality service by enhancing the patient experience, providing financial security, and preserving Duke’s reputation and mission of advancing health together. Our Vision is to be recognized as a world class innovative revenue cycle organization that values our people, patients and performance.

Compliance Specialist – Medicine/Radiology/Charge Capture/Charge Resolution

GeneralDescription of the Job Class :

Implement and maintain Compliance programs by the Office of Inspector General's work plan, to reduce institutional and individual provider legal and financial risk through education and internal audits.

Duties and Responsibilities of this Level:

·         Monitor and track performance to ensure quality and quantity of work performed through regular audits and QC for Coding and Non-Coding staff
·          Review and research complex medical records and/ or problematic coding that needs research and reference checking, and accurately codes, or guide coders for the primary/secondary diagnoses and procedures using            ICD-10 CM and/or CPT, HCPCS coding conventions, and payer-specific coding guidelines
·          Develop and assist with training, presentations, and educational tools for any relevant topic as it relates to continuing education programs in areas of specialization, coding, operational workflow, and quality control
·         Collaborates with other departments and partners (e.g. Revenue Integrity, QA Team, Compliance Specialists, Internal Controls, Billing and Collections, Revenue Managers, Coding Managers, and departmental                   leadership) to ensure optimized process and workflows
·         Consult with and provide feedback to physicians or departments on coding practices and conventions to provide detailed coding information. Communicate with clinical, ancillary staff, and Revenue Managers for needed documentation to ensure accurate coding
·          Develop and maintain a thorough understanding of anatomy and physiology, medical terminology, disease processes, and surgical techniques through participation in continuing education programs to effectively apply              ICD-10 CM and CPT coding guidelines to inpatient/outpatient diagnoses and procedures for both the Hospital and Professional claims
·         Develop and maintain a thorough understanding of medical record practices, standards, regulations, Health Care/Finance Administration (HCFA) and Uniform Billing (UB-04), CMS, and other payer policies and any                    healthcare-relevant changes
·         Develop and maintain a thorough understanding of payer-specific guidelines as it pertains to charge capture, edit review, denial management, and reporting
·         Attend various meetings with stakeholders, serving as a subject matter expert or as a Coding Operations delegate
·         Assist with Service Now ticket submissions for system logic updates
·         Ensure compliance with PRMO and DUHS policies and code of conduct
·         Ensure that the department’s operations adhere to the laws regulating the healthcare industry (i.e. CMS, Medicare, Medicaid, HHS, OIG, JCAHO)
·         Assist with special projects as required
·         Perform other related duties incidental to the work described herein

·         Coding and Non-Coding Quality Control (30%)
o     Review of Coding and Non-Coding staff to identify erroneous coding patterns and errors and provide feedback and education to address issues found
o    Monitor and track QA results by implementing the QA process in collaboration with the Revenue Integrity Team
o    Provide coding process analysis and support for the department as an expert for the PB Coding Medicine/Radiology/Charge Capture/Charge Resolution team Identify coding and documentation trends for use in the education of coding staff and providers
o    Review monthly QA report with the Coding Manager for quality  accuracy of coding staff members and team in aggregate
o     Review complex coding as a subject matter expert to provide additional guidance as needed
o    Implement and maintain Compliance programs focusing on work by Coding Operations by the Office of Inspector General's work plan, to reduce institutional and individual provider legal and financial risk through education and internal audits

·    Coding Education, Newsletter, and Team Development (40%)
o    Educate internal coders regarding compliance with government regulations with special attention to Center for Medicare and Medicaid guidelines as they pertain to academic medical centers, HIPAA, and Fraud and Abuse with periodic updates.
o    Plan activities, including specialty pod meetings, aimed at improving the quality performance of the PB Coding Medicine/Radiology/Charge Capture/Charge Resolution team and vendor coders. Design and implement strategies for enhancing the PB Coding Medicine/Radiology/Charge Capture/Charge Resolution te am and increasing productivity
o    Evaluate the effectiveness of improvement strategy through sustained tracking and monitoring of PB Coding Medicine/Radiology/Charge Capture/Charge resolution team WQs
o    Reporting of PB Cod ing Medicine/Radiology/Charge Capture/Charge Resolution team performance to the Coding Manager
o    Assist with research, development, and presentation of continuing education programs for specialty areas
o    Collaboration with the CS team on quarterly education sessions in Director All Staff Meetings and on quarterly coding newsletters
o    Maintain a thorough understanding of medical record practices, standards, and regulations, Joint Commission on Accreditation of Health Organizations (JCAHO), Health Care/Finance Administration (HCFA), Medical Review of North Carolina (MRNC), etc.

·         Vendor Relationships and Coding Onboarding (30%)
o    Manage vendor relationships through regular communications and routine audits of vendor coders. Communicate all internal controls and policies as applicable to the vendor coding team and mitigate any differences between vendor policy and University policy
o    Provide internal and vendor coder onboarding support to the Manager of Coding Operations – PB Coding Medicine/Radiology/Charge Capture/Charge Resolution 
o    Review of documentation guidelines for the coding of defined specialties for new employees or existing employees who are changing designated areas
o    Provide quality control review of internal and vendor coder onboarding cases and feedback to employee/supervisor regularly.
o    Provide a weekly summary to the Coding Manager / Supervisor on the progress of all employees

Perform other related duties incidental to the work described herein

Required Qualifications at this Level:

High School Diploma or equivalent however, Bachelor’s degree is preferred.


Four years of administrative experience to acquire competence in applying compliance, coding, and auditing principles as they relate to insurance billing, collections, consulting, and other revenue cycle-related functions.
Two of the four years of experience with OPPS, APC, OCE, MPFS, and NCCI is required. Experience in formal teaching of coding is preferred. CPC, COC, CPMA, RHIA, RHIT or CCS required.
Degrees, Licensure, and/or Certification:

Must hold one of the following active/current certifications:
Knowledge, Skills, and Abilities:

Advanced ICD-10-CM & amp; CPT coding conventions
Anatomy and Physiology
Medical Terminology
Critical Care Coding< /span>
Telehealth Coding
Multispecialty Coding including:  GI, Pulmonary, Cardiology, Cath/EP, Interventional Radiology, Radiology
Extensive E/M leveling familiarity
Effective written and verbal communication skillsAbility to communicate with customers/staff with diverse educational backgrounds
Ability to provide feedback and education in a group setting or over Teams or Zoom
Analysis of data and processes for opportunities for improvement
Attention to detail and accuracy

Minimum Qualifications


Work requires organization, analytical, and communication skills program. generally acquired through the completion of a Bachelor's degree


Four years of administrative experience to acquire competence in applying compliance, coding, and auditing principles as they relate to insurance billing, collections, consulting, and other revenue cycle-related functions. For technical coding, two of the four years of experience with DRGs and APR-DRGs is required. Experience in formal teaching of coding is preferred. RHIA RHIT or CCS required. For professional coding, specialty coding experience in surgical or E/M coding is preferred. CPC or CCS or RHIT RHIA or CPMA is required.

Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas—an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the community feel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essentialjob functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.

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