Manager, Government Audits and Appeals

The Manager of Government Audits and Appeals directs the external government audit response and appeal process for UPHS Hospitals, Home Care and Hospice Services, Practice Plans, with specific emphasis on the Recovery Audit Contractor (RAC) implementation and response team. The position is responsible for the day-to-day management of UPHS third-party payer claims reviews, including coordinating activities of all individuals throughout UPHS involved in appeals.

Primary duties include:

• Management and ongoing development of workflows, policies and procedures, and the communication plan to prepare government audit requests and denials. Develops changes to organizational practice, policies and procedures, as needed.

• Responsible for planning, coordinating and managing audits and educational programs to limit external audit risk

• Monitoring the overall government audit effect on UPHS. Preparation of executive reports for Senior Leadership.

• Serves as Systems Administrator for Medicare/Medicaid/Commercial Audit tracking tool

• Assumes a leadership role as Chair of the interdisciplinary RAC team (Patient Accounting, Medical Records, Case Management, Practice Plans/HCHS Administration, and Compliance) to achieve optimal outcomes

• Provides feedback to UPHS' efforts to improve documentation of hospital and professional services based on audit findings and appeal success

Accountabilities

• Manage external government and other third party audits to include but not limited to RAC (Medicare and Medicaid), Medicare Administrative Contractors (MAC) to include Targeted Probe and Educate (TPE), Zone Program Integrity Contractor (ZPIC)/Unified Program Integrity Contractor (UPIC), Office of the Inspector General (OIG), Qualified Independent Organization (QIO), Comprehensive Error Rate Testing (CERT), Supplemental Medical Review Contractor (SMRC) and the Bureau of Program Integrity (BPI)/Department of Public Welfare (DPW)

• Leads meetings to plan, implement and monitor audit efforts

o Guides “External Government Audit Committee” efforts

o Works with interdisciplinary team to develop process to communicate audit findings and establish UPHS department response expectations

o Monitors agency websites and other publications for (potential) upcoming audits

o Communicates Medicare and Medicaid matters regularly to Administration, Patient Accounting, Case Management, Medical Records, practice plans, and other settings (eg: Home Health)

o Monitors new industry developments; implements and/or coordinates implementation of new processes related to those developments as necessary

o Works collaboratively with various departments in the interest of favorable financial outcomes related to external government audits with an emphasis on RAC, Medicare (to include TPE), DPW, MIC and ZPIC audits

o Educates and provides insight into audit and appeals process to UPHS end users

o Responsible for registration with RAC and other audit entities

• Serves as facilities’ liaison to CMS, RAC and other governmental audit contractors (to include OIG and the U.S. Attorney)

o Manages compliance information to include notification of pertinent issues to the UPHS leadership and the Office of General Counsel, and prompt investigation of reported issues

o identifies circumstances where the assistance of legal counsel should be sought

• Directs appeals process for coding and validation reviews

o Coordinates with external appeals vendor, if necessary

§ Serves as first level liaison with external appeals vendor for issues both on appeals and concurrent operational issues

o Works with VP/Billing Compliance officer on contract negotiations with vendor as needed

• Reviews medical documentation and provides feedback to facilitate improvement in documentation and coding

o Implements education for multiple disciplines (coding, case management, physicians, patient accounting) and initiates process changes as indicated

• Prepares appropriate cases for appeal submission with reevaluation as needed at each subsequent step of the Medicare appeal process

o Develops rebuttal letters utilizing pertinent State and Federal regulations as well official correct coding guidelines

o Assists and supports on appeals involving Administrative Law Judge by preparing supporting documentation and appropriate research as needed

• Manage and expedite special reviews, investigations of allegations, focused medical reviews and external audits of all UPHS areas

o To include active participation with focused audits related to RAC and other governmental audit activity

• Direct supervision of the Coordinator or Analyst, Government Audits and Appeals

o Monitors daily productivity and accuracy

o Conducts performance evaluations

o Assists with addressing challenges and skill deficits

o Provides support and guidance

o Establishes effective and ongoing communication

• Serve as UPHS system administrator for audit tracking software

o Trains end users on audit tracking software to include internal and external staff (Release of Information vendor)

o Provides administrative and technical support to end users at all entities (to include but not limited to hospital, practice plans, and other settings)

o Develops, implements and monitors the completion of enhancements and major application upgrades

o Coordinates claims audit software system upgrades and enhancements and educate users on new system functions

o Tests claims audit software enhancements

o Troubleshoots and resolves system issues

o Acts as a liaison between UPHS and software vendor to resolve issues and promote future enhancements based on UPHS needs

o Monitors claim upload by Information Services into claims audit software

• Conduct Data Analytics on internal data to

o Assist in developing internal strategies on efficiency and quality

o Conducts Internal Audits based on data

o Interprets data and analyzes results using statistical techniques and provide ongoing reports

o Prepares report of findings for Leadership

• Prepare and present summary reports for Senior Leadership

o Conducts in-depth analyses of government audit and findings to identify opportunities for billing and coding education and improving organizational practices, policies and procedures

o Collects data on audit activities including type of claims being reviewed, adverse determination rates, the status and success of appeals, and cost-benefit of response activities (recoupments/refunds), including appeals

• Facilitate processes and systems that support the UPHS goals for compliance

o Meets regularly with Director to ensure client needs are met

o Participates in departmental quality assurance programs

o Gathers pertinent government rules and regulations

o Creates review specific work papers

o Participates in planning, negotiating and implementing new programs to the Office of Billing Compliance while maintaining full coordination with the VP/Billing Compliance Director

• Provide technical assistance to VP/Billing Compliance Officer regarding financial planning, budgeting, monitoring, focused audits (internal and external) and execution

o Perform cost-effective analysis for any new programs

o Respond to institutional requirements to adjust budget owing to program expansion as well as retrenchment

o Coordinates with VP/Billing Compliance Officer to update end users on third party reserves

§ Provides updates to third party vendor in compliance coordination in regards to third party reserves

o Works with VP/Billing Compliance Officer on third party reserve calculations for new audit issues that arise

o Perform statistical analysis and applies sampling techniques for focused audits (internal and external)

§ Assists with writing, editing, and any additional modifications of audit work papers, report writing, and final report submission to internal or external parties

• Maintain confidentiality with respect to medical records and corporate documents (HIPAA, JCAHO, etc.)

• Performs duties in accordance with Penn Medicine and entity values, policies, and procedures

• Other duties as assigned to support the unit, department, entity, and health system organization

Minimum Requirements

Required Education and Experience

• Bachelor's Degree is required.

• 5+ years of experience in a related field is required

• Master's Degree is preferred

• Previous supervisory and/or management experience

• Knowledge of medical terminology, ICD-10, and other coding. Patient Revenue Cycle, Federal, State, and other third party regulations, including appeals management. Familiarity with IPPS, OPPS.

• Experience with application administration.

Licenses, Registrations, and Certifications

• Coding certification (CPC or CCS) is preferred

Required Skills and Abilities

• Strong written and verbal communication skills, including public speaking

• Ability to manage and execute projects timely, efficiently, and cost-effectively

• Strong leadership skills

• Ability to define and resolve critical issues

• Proficiency with medical record review with an emphasis on documentation requirements

• Familiarity with hospital and professional fee coding

• Proficient in MS Word, Excel and PowerPoint

As part of our COVID-19 response, this position may currently be offering partial or full remote work. However, in the near future this position will require full or partial on-site work.

• Strong leadership skills

• Ability to define and resolve critical issues

• Proficiency with medical record review with an emphasis on documentation requirements

• Familiarity with hospital and professional fee coding

• Proficient in MS Word, Excel and PowerPoint

As part of our COVID-19 response, this position may currently be offering partial or full remote work. However, in the near future this position will require full or partial on-site work.