The Regulatory Manager evaluates existing Stony Brook Community Medical (SBCM) practices for compliance with service performance and utilization by reviewing medical records. The goal is to implement compliance activities in SBCM working with key medical and clinical leadership. This includes the design, coordination, implementation and evaluation of those activities. Achieving desired clinical outcomes is the mission of SBCM. In addition, reviews, analyzes and assures the final diagnoses and procedures as stated by the practicing providers are valid and complete.Verifies accuracy of coders office and hospital procedures for providers to ensure proper reimbursement. Provides education to the providers to ensure proper completion of EMR and assignment of ICD-10-CDM, HCPCS and CPT codes.
Essential Job Functions:
Review medical records to assess appropriate level of patient care.
Review treatments, tests, procedures and orders to assure that documentation supports ‘medical necessity’.
Lead team to collect data on health outcomes and practice quality.
Observe patient confidentiality in accordance with HIPPA.
Ensure SBCM practices reduce the hospital readmission rate of high risk patients
Audits medical records to ensue proper coding completed and to ensure compliance with federal and state regulatory bodies
Accurately follows coding guidelines and legal requirments to ensure compliance with federal and state regulatory bodies.
Determines the final diagnoses and procedures stated by the physician other health care providers are valid and complete
Performs a comprehensive review for the record to assure the presence of all component parts of all reports appear to in be indicated by the nature of the treatment rendered.
Evaluates the record for documentation consistency and adequacy.
Ensures that the final diagnosis accurtely relects the care and treament rendered.
Reviews the records for compliance