Regulatory Compliance Administrator Hybrid/Remote

The Regulatory Compliance Administrator collaborates with providers, managers, and staff to assist departments, clinics, and/or service lines in implementing, coordinating, and monitoring compliance practices.

This incumbent is responsible for conducting medical necessity audits by reviewing clinical practice standards and documentation. The incumbent will conduct and respond to audits and projects related to regulatory and payment integrity to ensure accurate and timely responses to governmental contractors. In addition to the clinical expertise needed for the medical necessity reviews, the incumbent will perform scheduled and unscheduled regulatory and payment integrity audits, develop and standardize policies and procedures, training and education, compliance investigations, and reporting to ensure compliance with University, State, and Federal guidelines.

The incumbent must be highly skilled in time management and possess strong communication skills. The incumbent will work with their team to evaluate and review individual skills and knowledge level and assign tasks accordingly. Must be able to provide mentoring to supporting roles within the team.

This position is not responsible for providing patient care. This position has the possibility of remote work.

Responsibilities

Essential Functions:

1. Maintains current knowledge regarding federal and state guidance, organizational needs, and regulations.
2. This position prioritizes governmental and internal audit requests and needs based on risk, timelines, and available skilled personnel.
3. Reviews documentation for medical necessity and utilizes industry standard tools such as InterQual or Milliman.
4. Teams with providers and staff to assist departments in implementing compliance practices and monitors and coordinates those activities with the departments.
5. Assists the University in preparing and completing regulatory audits by developing, monitoring, and updating quality controls and recommending actions to maintain compliance.
6. Oversees, coordinates, and conducts audits/investigations to ensure compliance with University, State, and Federal guidelines.
7. Analyzes and documents compliance processes. Recommends enhancements to policies and procedures for compliance review.
8. Designs and implements training and education programs to enhance compliance awareness.
9. Serves as an expert resource in compliance issue resolution.

This job description has been designed to indicate the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to the job

Work Environment and Level of Frequency typically required

Nearly Continuously: Office environment.

Physical Requirements and Level of Frequency that may be required

Nearly Continuously: Sitting, hearing, listening, talking.

Often: Repetitive hand motion (such as typing), walking.

Seldom: Bending, reaching overhead.

Minimum Qualifications

Current licensure to practice as a Physician’s Assistant in the State of Utah and minimum three years of experience in a patient care capacity OR current licensure to practice as a Registered Nurse ( BSN or APRN ) in the State of Utah and minimum five years of experience working in a patient care capacity or equivalency (one year of education can be substituted for two years of related work experience). Patient care experience may be substituted with equivalent years of experience in medical necessity review. Must be proficient with word processing, spreadsheet and related computer applications and have exemplary human relations and effective communication skills. Requires a sound knowledge of clinical practice and exceptional critical thinking and leadership abilities. Department may require coding certification ( CPC , ACS , CCS -P/H, RHIA , or RHIT ).

Preferences

Knowledge of utilization review and quality assurance procedures as well as experience with InterQual or Milliman and Robertson and Case Management procedures of medical necessity auditing.

This position is patient-sensitive and must fulfill all associated requirements. We protect our patients, coworkers, and community by requiring all patient-sensitive employees to be immunized according to CDC standards and hospital policy. Limited exemptions may be made for documented medical contraindications or religious beliefs that object to vaccinations.

Preferences

1. Knowledge of utilization review and quality assurance procedures, as well as experience with InterQual or Milliman and Case Management procedures of medical necessity auditing.
2. Bachelor’s Degree in Health Care Administration, Business Administration, or a related field, or the equivalent.
3. Knowledge of medical auditing, Federal healthcare program policies and requirements (including Medicare Parts A and B), and ICD -10, CPT , HCPCS , DRG coding.
4. Coding certification ( CPC , CPC -H, ACS , CCS -P/H, RHIA ). If not current, must be willing to obtain within the first six months of employment.
5. Certified in Healthcare Compliance ( CHC ) from the Health Care Compliance Association ( HCCA ). If not current, must be willing to obtain within the first six months of employment.