Compliance Specialist

North Carolina, United States
19 Oct 2018
End of advertisement period
19 Dec 2018
Contract Type
Full Time


Job Description

General Description of the Job

Class Implement and maintain Coding Compliance programs in accordance with the Office of Inspector General's work plan, to reduce institutional and individual provider legal and financial risk through internal audits, training and education. Additionally increase revenue, accuracy of payment and quality of care with improved documentation by identifying, training/educating, capturing and submitting valid medical diagnosis

Duties and Responsibilities of this Level


  • Thorough understanding of clinic coding (E/M) documentation requirements and HCC concepts impacting population Health Risk Adjustment reimbursement initiatives
  • Ability to review documentation and abstract all codes with specific emphasis on identifying the most accurate severity of illness according to CMS HCC guidelines
    • Leverage Healthcare Effectiveness Data and Information Set (HEDIS) to measure provider performance on important aspects of care and service
    • Collaborate with CDI Representative to provide timely feedback that will assist with validating and reporting appropriate measures of accuracy
  • Offers recommendations and develops templates and tips for capturing the HCCs at the patient encounter
  • Serve as HCC subject matter expert in conjunction with CDIS program lead(s) to providers, practice managers, PRMO leadership, and Duke Health stakeholders
  • Coordinate activities related to Coding Quality Assurance/Audit. Be actively engaged in coding, abstracting and medical data research to include review and analysis of data input, processing and data output activities. o Develop and present educational training programs to hospital and medical coding staff, and maintaining educational collaborations such as Bulletin Review from Payers and review of coding queries.
  • Conducts both random and focused reviews on a regularly scheduled timeframe for accurate documentation and coding which is then reported to coding operations.
  • Identifies coding and billing risk areas and communicates timely through the appropriate channels/forums those areas that require escalation.
  • Collaborates with internal staff in development of improved capabilities in coding and compliance.
  • Responds promptly to external and internal concerns with regard to correct coding policies. Identifies errors on claims and sends to the Claim Correction Department for processing.
  • Assists with education of providers in regard to compliance and government regulations with special attention to CMS and Medicaid guidelines as they pertain to academic medical centers, HIPAA, and Fraud and Abuse with periodic updates.
  • Maintains knowledge regarding policies and procedures with Medicare/Medicaid Carriers and third party payers; including HCC and RAF guidelines
  • Collaborates with Internal Compliance Department to promote excellence in correct documentation and coding.
  • Interacts effectively and professionally with colleagues to provide helpful information in response to inquiries, concerns and requests.
  • Develops and maintains strong working relationships with both internal and external customers.


  • Provides documented education ( e.g. PPT, handouts, training materials, etc. to be posted to the Quality Audit/Review Share Point).
  • Presents 4 – 7 education sessions each year with evaluations
  • Assists in the financial goals of the department through individual efforts as well as encouraging excellence in others via collaboration.
  • Adheres to all internal policies.
  • Actively promotes a better DUHS work environment and a positive atmosphere in which to work.
  • Exemplifies DUHS core values and encourages othersto follow this high standard.
  • Shows respect and values others at all times.
  • Participates in multiple employee engagements that align with covenant mission


  • Performs other duties as assigned by management Perform other related duties incidental to the work described herein:
  • Maintains all coding credentialing for I-10, HCC and other training and education.
  • May participate in payer testing
  • May work with HLI staff and DUHS IT staff to provide data analysis
  • May work collaboratively with IMO/MC teams to identify critical language/coding needs.
  • Anticipates needs of DUHS regarding I-10/I11 data analytics, preference list and mappings/crosswalks

Requisition Number 401494592 
Location Durham 
Duke Entity PRMO
Job Family Level F2
Exempt/Non-Exempt Non-exempt 
Full Time / Part Time FULL TIME
Regular / Temporary Regular
Shift First/Day

Minimum Qualifications

Duke University 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 essential job 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.


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


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 professional coding, specialty coding experience in surgical or E/M coding preferred. CPC or CPMA is required.

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