Job Description

Job Title: Director Physician Services, Audit and Compliance
Job ID: 78916338
Status: Full-Time
Regular/Temporary: Management
Hours:
Shift: Day Job
Facility: Corporate Finance
Department: Internal Audit
Location: 3600 Forbes Ave, Pittsburgh PA 15213

Description

The Director Physician Services, Audit and Compliance is responsible for staying current with and identifying emerging risks and regulations in healthcare that could affect the company. The primary responsibilities of this position are to
manage and deliver internal audit and compliance activities to assure they are conducted according to professional standards with the goal of maximizing value for the company. Current activities include physician and advanced practice professionals billing and coding audits, internal audit engagements throughout the system, data analytics, process improvement projects, special investigations and special projects as requested by management. Compliance functions include all seven elements of an effective compliance program. Direct multiple projects concurrently including refining the scope based on risk assessment, executing fieldwork, workpaper review, preparing reports and monitoring of followup. Present audit conclusions and value-added recommendations to Senior management that reflect a strong understanding of company objectives and capabilities, control requirements, and industry best practices to facilitate change in a constructive and collaborative manner. Assist the departmental senior leadership team in developing risk assessments and the annual compliance and audit plans. Oversee the execution and review of work of auditors and analysts to assure work is of high quality, timely and in accordance with overall department objectives and guidelines. This position will identify trends with billing and coding a well as audit and consulting best practices that can be implemented in the department in order to more effectively provide value to our customers. Supervise, mentor, and provide performance management for staff working on assigned engagements. Participate in the interview process of potential auditors and analysts and provide strong leadership in recruiting, building and developing talent at various
levels.

Responsibilities:

Compliance Activity:  
  • Lead the physician services audit and monitoring function over billing and coding for all care providers.
  • Identify a risk-based approach to the audits that include consideration of the OIG Workplan, NCD/LCDs, and billing guidelines that are new, changed, or frequently identified as complex or having inappropriate billing issues.
  • Utilize data analytics to qualify the population and target samples that best protect UPMC as well as evaluate the accuracy of clinical documentation and billing.
  • Develop and manage compliance programs to achieve compliance with regulations, rules and standards or conduct.
  • Establish policies and procedures to support compliance activities.
  • Plan, develop and conduct communications and educational and training sessions related to specific compliance topics.
  • Establish monitoring mechanisms and conduct routine audits and compliance programs. Oversee coordination and facilitation of the work of compliance officers/liaisons across assigned areas as well as individuals and groups throughout these UPMC departments/divisions, across a wide range of compliance topics.

Departmental Goals and Time Management:

  • Contributes to defining and meeting departmental goals. Successfully manages many competing demands and is able to deliver projects on time and within budgeted hours.

  • Assists the department in making sure that staff analysts and auditors are productive and have adequate work load.
  • Meets departmental goals for productivity and monitors deadlines for reports, follow-up and Board reporting. Proactive in identifying staff downtime and assists in helping staff to stay productive.
  • Identifies opportunities for process improvements within the department and efficient resolutions for them. 
  • Industry & Technology Skills:
  • Possesses strong understanding of business process controls. Has developed specialized skills in the industry or specific divisions of UPMC.
  • Possesses advanced knowledge of internal and external control expectations, including UPMC Standards, GAAP, IIA, COSO, Six Sigma, fraud and SOX. 
  • Utilizes various infonet, social media and communication tools available in the organization to communicate compliance topics. 
  • Contributes to ongoing departmental goal of entity-wide risk identification and logging for the creation of both the compliance and audit plans.
  • Possesses solid understanding of healthcare terminology, billing and coding regulations and guidelines and industry risks, understands their impact on UPMC, and can serve as a resource to clients for inquiries.
  • Able to research and analyze new business processes and new programs to identify key controls and risks as well as conflict of interest and regulatory considerations.
  • Able to conduct a walk-through and demonstrate a strong understanding of business
  • processes and create or supervise a process flow to review with the client.
  • Able to utilize understanding of complex business processes and issues and UPMC as a whole to recommend appropriate controls to mitigate risks while aligning with strategic goals, business objectives and regulatory expectations. Maintain a strong understanding of the applicable billing applications to assess and develop solutions when issues are identified.
  • Possesses advanced auditing and software skills with department applications (Microsoft Office, Audit Workpaper Software, and ACL).

 

Leadership skills:

  • Participates in and frequently leads departmental special projects. 
  • Assists in developing and maintaining department independence, professionalism, and reputation.
  • Participates in departmental meetings, including, contributing to agenda, presenting and educating co-workers. 
  • Possesses strong public speaking skills and is comfortable leading opening and closing meetings, including explaining issues to executives and handling constructive disagreements to resolution.
  • Assures that the appropriate levels of UPMC management are aware of projects and issues.
  • Mentors and/or develops staff skills, judgment, and effectiveness.
  • Facilitates individual as well as staff and departmental team work and team building.
  • Provides constant feedback to staff analysts and auditors on their performance and is able to train staff analysts and auditors on appropriate tools and techniques of auditing and monitoring and internal auditing.
  • Completes performance reviews on audit projects and contributes to coworkers and staff.
  • Performs in accordance with system-wide competencies/behaviors.
  • Performs other duties as assigned.
  • Professionally represents the CACO, VP or Director at delegated meetings or projects. Develops and maintains a resource network of contacts and effective working relationships with executive management within UPMC, as well as external leaders and peers.

 

Workpaper & Report/ Deliverable Preparation:

  • Uses, reviews, and initiates revision of the standard department templates and processes for performing internal audits as well as auditing and monitoring.
  • Capable of developing completely new work programs and testing steps to be included on audit programs.
  • Workpapers are completed on time
  • and evidence is organized to fully support conclusions and findings.
  • Open items and review comments are fully tracked and closed within timeframes.
  • Provides substantive review notes and establishes reasonable deadlines to auditors.
  • Identifies root cause of complex issues and proposes valuable and effective solutions, with knowledge of UPMC organization.
  • Tracks and trends issues identified in auditing and monitoring results to provide appropriate communication and education as well as determine future approaches to audits and sample sizing to best identify and resolve issues proactively.
  • Reviews all workpapers as appropriate and finalizes report drafts for review by Management.
  • Reports are professional, complete, practical, based on accepted standards, and all findings validated
  • with client.
  • Follow-up for past audits is tracked and performed within timeframes to meet reporting requirements.
  • Monitors and tracks all audits under supervision for proper inclusion and reporting to the Audit Committee and the Ethics and Compliance Committee.

Qualifications

  • Bachelor's degree in legal, accounting or other related business field required. 
  • Minimum of six years of experience with a CHC, CIA or other relevant certification; risk and control-focused areas such as regulatory or internal auditing or equivalent experience in a health care field is required. 
  • Significant leadership experience required. 
  • Relevant professional certification is required. 
  • Master's degree and/or Six Sigma Certification are preferred. 
  • Significant experience in a management capacity. 
  • Strong understanding of risk analysis and process improvement. 
  • Superior technical skills, including superior knowledge in Access, Excel, Power Point, Visio and SharePoint.  
  • Knowledge of industry standard project management tools, methods and reports.  
  • Excellent verbal and written communication skills with the ability to work effectively with all levels of the organization. 
  • Relevant professional certification is required. (CPA, CIA, CMA, others)

Licensure, Certifications, and Clearances:
Relevant professional certification is required. 
(CPA, CIA, CMA, others)


UPMC is an Equal Opportunity Employer/Disability/Veteran

Salary Range: $0 / hour

Union Position: No

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