Nurse Practitioner - QA and Compliance

GENERAL PURPOSE:

The Nurse Practitioner/Physician Assistant will strive to ensure compliance with the applicable federal and state laws, rules and regulations, to prevent improper conduct and to promote quality, integrity, and honesty in all our dealing with third-party payers. The compliance program is designed to enhance and demonstrate the Company’s commitment to achieving the highest lever of awareness of governmental, legal and ethical requirements. The Compliance program also bears responsibility for ensuring the Company complies with Anit-kickback laws and for implementing regulations, including the Federal physician self -referral laws and “Stark Law” regulations, Fraud and Abuse regulations. This position will assess compliance with CMS Medical Necessity standards of care when billing Evaluation and Management (E/M) encounters to Medicare, Medicaid and 3rd party Payers in the Post Acute/Long Term Care Setting.

QUALIFICATIONS

· Must be a Registered Nurse and Certified Registered Nurse Practitioner or Physician Assistant in good standing and meet all applicable licensure standards in the State of Alabama for advanced practice.

· Must be familiar with Medical Necessity standards of care when billing Evaluation and Management (E/M) encounters to Medicare, Medicaid and 3rd party Payers in the Post Acute/Long Term Care Setting.

· Must have knowledge in clinical duties of Nurse Practitioner/Physician Assistant practice

· Knowledge and experience in working in the long term care environment

· Must possess the ability to communicate effectively and deal tactfully with Nurse Practitioner/Physician Assistant practice members, facility staff members, facility patients and staff members, the medical community, and other customers.

· Computer literacy and knowledge of electronic medical record documentation. You will be trained in the software developed for this practice.

· Capable of maintaining regular attendance.

· Must have patience, tact, enthusiasm, and positive attitude toward the elderly and disabled.

· Must be able to speak, read, write, and understand English.

· Must be capable of performing the ESSENTIAL JOB FUNCTIONS AND PHYSICAL AND SENSORY REQUIREMENTS FOR ALL JOB FUNCTIONS as outlined below:

STANDARD REQUIREMENTS

· Support the Mission, Values, and Vision of Southern NP Associates, LLC and affiliated companies.

· Knowledgeable of resident rights and ensures an atmosphere which allows for the privacy, dignity, and well-being of all residents.

· Report to management immediately all instances of misappropriation/handling of resident property.

· Support, cooperate with, and implement specific procedures and programs for:

a) Safety, safe work practices, established fire/safety/disaster plans, risk management, security, report and/or correct unsafe working conditions, equipment repair and maintenance needs.

b) Maintain confidentiality of all data, including resident, employee, and operations data.

c) Comply with all regulatory requirements.

d) Comply with current law and policy to provide a work environment free from sexual harassment, and all illegal and discriminatory behavior.

· Support and participate in common teamwork.

· Cooperate and work together with all co-workers.

· Plan and complete job duties with minimal supervisory direction, including appropriate judgment.

· Use tactful, appropriate communications in sensitive and emotional situations.

· Follow up as appropriate with supervisor on reported complaints, problems, and concerns.

· Complete requirements for training, acceptable attendance, dress code including personal hygiene, and other work duties as assigned.

· Provide great customer service to internal & external customers.

· Promote positive public relations with residents, family members, and guests.

· Support facilities and facility staff in a friendly, courteous, and cooperative manner.

· Comply with all company policies and procedures regarding HIPAA Privacy and Security, the company’s Corporate Compliance and Quality Assurance program requirements, including the Code of Conduct, Abuse, and state mandated requirements in accordance with Federal requirements.

SPECIFIC DUTIES

· Each month, two months in arrears, a list of random patient encounters with dates of service for the month being audited is created. The auditor shall process the data to identify and report on the number of visits per patient in places of service relative to Nursing Facilities. The encounters selected for these reports are generated by a query that identifies the number of encounters conducted on the same patients in the calendar month. The first report will list all NF patients with eight (8) or more billed encounters for the month, and the second will list all SNF patients with twelve (12) or more billed encounters for the month. These reports will include Patient #, Patient Name, Place of Service and number of visits.

· The reports will be produced through Excel Spreadsheets.

· To ensure that no provider is missing, providers who have not been selected in the previous 3 months randomization process will be selected, and a list of their patients will be generated by place of service.

· Once the patient encounters have been selected, a randomized report will be generated listing the selected patients and all their billed encounters for the audit. The report will include Patient Name, Patient #, Date of Service, Encounter Number, Place of Service. Practice Name, Provider Name, Location and Provider Name.

· The auditor will review each note for appropriate medical necessity and appropriate level of service and will complete an audit form for each encounter on the basis. Additionally, the entirety of the visit conducted on the patient will be audited for Compliance with customary standards of care as it relates to the number of encounters submitted for billing. Any encounter found to potentially lack medical necessity will be reviewed more thoroughly in conjunction with the Practice Manager or Designee. If no consensus is obtained the auditor’s opinion will be utilized if the employee is no longer with the company. This step should be completed by the end of the month in which the audit was started.

· Audit results should be provided to the Executive Director and Compliance Officer Liaison. Reports shall be received upon completion or by the end of the month.

· Auditor will determine the content of the note to ensure consistent with accuracy and level of medically necessary as outlined by AMDA guidelines for charting in long-term care.

· Audit Transition of Care visit /Care planning meetings held per protocol

· All other duties as assigned