The Director of Coding Compliance develops and directs , in coordination with the Sutter Health Ethics and Compliance Program, a coding, documentation and data quality compliance program for Sutter Health. Establishes system wide coding compliance standards and policies related to charge capture and facility and professional coding and billing practices. Provides guidance and education designed to promote regulatory charge capture, coding and billing compliance in Sutter Health's Health Information Management (HIMS) departments, Medical Foundation Departments, Home Health and Hospice Department, Ambulatory Surgery Departments and all departments responsible for revenue generated for the purpose of charge capture, coding, billing and reimbursement. Provides oversight and guidance to the Manager of the Documentation and Data Quality to promote documentation and data quality, compliant billing, charging and HIMS/Revenue Cycleoperational practices as required by Federal and state legal requirements and payer policies. Provides support to the Managed Care Contracting Team during arbitration as a Subject Matter Expert (SME) in matters related to charge capture, coding, billing and reimbursement. Provides leadership and direction to the system'sHIMS professionals, and to physicians, nurses, clinicians, department managers, revenue cycle departments throughout Sutter Health. Assesses potential and existing risks in regulatory and/or coding practices, and conducts or coordinates research as needed to provide guidance and awareness of identified risks, answer questions and resolve coding, documentation and data quality compliance issues identified through the Ethics and Compliance Program, the Internal Audit Department, the Office of General Counsel, and by others within and outside of Sutter Health. Provides support as the SME for internal and external billing, coding, and revenue cycle operational assessment, reviews and, audits. Co-chairs the Affiliate Coding and Operational Resources Network (ACORN) Oversight Committee; participates as an advisory member of the Executive Compliance Committee, the Revenue Cycle Integrity, Steering Committee, The Denials Management Committee, and the Ethics and Compliance Services Leadership Team. Provides support to the Medical Foundation and Hospital Revenue Cycle Departments for all charge capture, billing, coding and, reimbursement issues. EducationBachelor's degree in In health care related field required or equivalent education/experience Master's degree preferred
LicensureRegistered Health Information Administrator - RHIA preferredRegistered Health Information Technician - RHIT preferredCertified Coding Specialist - CCS preferred
Certified in Healthcare Compliance - CHC required.
Doctor of Medicine - MD preferred
Attorney - ATT-JD preferred.
Experience3-5 years experience in coding and health information management as typically acquired in eight years is required; including experience in a supervisory capacity, supervising coders or coding related positions in a physician, hospital or clinic setting as typically acquired in approximately four years required. 3-5 years experience in researching complex coding compliance issues and questions, and ability to develop effective education programs for adult learners (coders, physicians, nurses) is required.3-5 years Experience working with a governing Board and senior leaders is strongly required required.
Skills and KnowledgeMust be well versed in documentation and coding requirements for professional services and for both inpatient and outpatient hospital and ancillary provider settings.Knowledge of CMS rules and regulations and current coding resources including CPT, ICD-9-CM, ICD-10-CM, HCPCS, fee schedule and HCCs.Must have a working knowledge of management of an effective ethics and compliance program, including training, monitoring, conducting and documenting investigations, addressing violations and monitoring corrective actions.Knowledge of healthcare compliance requirements strongly desired.Knowledge of other disciplines outside of own area of expertise, including business planning, clinical disciplines, human resources, finance, clinical and financial auditing, and information technology is desired.Must have demonstrated current knowledge of business ethics and legal and compliance risks and the knowledge to manage those risks in a dynamic health care environment.Should have working knowledge of federal and state reimbursement program requirements (e.g., Medicare and Medi-Cal), federal and state anti-kickback and physician self-referral laws (e.g., Stark and PORA), and provider and practitioner licensure and scope of practice requirements, privacy and consent laws.Requires excellent written, verbal and group presentation skills. Must have demonstrated strong leadership skills, the ability to manage projects across the system is required, including the ability to positively influence others without direct lines of authority to a positive outcome.