Medicare Risk Adjustment Chart Review Jobs in Utah

Description

 The Compliance is responsible for ensuring Telos maintains full compliance with State of Utah licensing requirements, Joint Commission standards, and the requirements of Medicaid and third-party insurance payors across all campuses. This role oversees clinical documentation quality, critical incident management, staff training and accountability, payor and insurance compliance, facility safety and risk mitigation, and organizational readiness for regulatory inspections.

DUTIES & RESPONSIBILITIES

1. Clinical Documentation and Charting Compliance

• Conduct regular chart reviews to audit clinical documentation for charting compliance.
• Perform clinical hours audits to verify clients are receiving 20 hours per week..
• Review charting quality for proper clinical language, terminology, and completeness.
• Train clinical and direct-care staff on documentation standards, charting expectations, and correct clinical language.
• Partner with Bridgeway Billing to train staff on documentation practices that support accurate, compliant billing.
• Monitor level of care changes and update client charts to reflect the new level of care.

2. Critical Incident Management

• Submit critical incident reports to the State of Utah in accordance within 1 business day.
• Assist in CPS and law enforcement reporting when needed.
• Review each critical incident to determine root cause and identify which incidents were preventable by staff action or inaction.
• Develop and implement corrective action plans and additional targeted training following preventable incidents.
• Pull and review camera footage related to incidents and use it as a training tool with staff.
• Track incident trends over time and report findings to leadership.

3. Staff Training and Compliance Accountability

• Partner with Human Resources to address and discipline staff for compliance violations.
• Ensure quality documented training is being delivered consistently and effectively across all campuses.
• Design and facilitate engaging, effective additional trainings on compliance, safety, and clinical topics.
• Train staff on Policies & Procedures (P&P) and ensure understanding of expectations.

4. Regulatory and Licensing Compliance

• Maintain thorough, current knowledge of State of Utah licensing requirements applicable to the facility.
• Ensure ongoing organizational compliance with State of Utah licensing standards.
• Ensure ongoing compliance with Joint Commission accreditation standards.
• Serve as primary point of contact for all state announced and unannounced visits, surveys, and inspections.
• Manage licensing renewals and resubmissions to ensure no lapse in licensure.
• Monitor regulatory changes at the state and accreditation level and update internal practices accordingly.

5. Payor and Insurance Company Compliance

• Ensure ongoing compliance with the requirements of Medicaid and all third-party insurance payors.
• Maintain and manage insurance credentialing for the facility and clinical staff.
• Respond to and manage insurance recoupment requests, including coordinating supporting documentation and appeals.
• Lead and response to payor-initiated quality of care investigations.
• Track and respond to payor audits and chart/record requests.
• Assure short-notice peer-to-peer calls happen. 

6. Facility Safety and Risk Management

• Conduct building safety walk-throughs to identify and address hazards.
• Document risk mitigation efforts and maintain risk management records for the facility.
• Walk the building weekly to identify maintenance issues and cleanliness concerns.
• Create and manage systems of accountability for cleanliness across the facility.
• Hold maintenance staff accountable for the overall condition of the building.
• Oversee and manage custodial operations.
• Identify areas of the building in need of remodeling, cosmetic updates, or improved decor, and lead efforts to make those spaces more attractive and welcoming.

7. Records, Documentation & Systems Administration

• Maintain and organize all critical compliance documents, including fire inspection reports, business license renewals, and county health certificates.
• Handle legal issues in conjunction with company attorneys.
• Lead development and ongoing maintenance of the Bluestep EHR system.
• Organize and maintain the company's Drive folder and file structure.
• Maintain and update the Policy & Procedure (P&P) manual and blueprints.
• Ensure vehicle maintenance records are complete, accurate, and up to date.

8. General Liability Insurance Management

• Manage annual renewal of the organization's general liability insurance policies.
• Handle general liability insurance issues and claims as they arise.

9. 501c3 Compliance for Telos Academy

• Assure Telos charitable organizations are in compliance with federal and State rules.

10. Additional Responsibilities

• Inspect vehicles and maintain maintenance records
• Manage and maintain the outcomes research program
• Maintain a compliance calendar to track license renewals, inspection dates, credentialing deadlines, and required filings.
• Prepare the organization for mock surveys and inspections to ensure ongoing readiness.
• Support emergency preparedness planning and drills (fire, safety, evacuation).
• Monitor HIPAA and privacy compliance across campuses.
• Assure annual safety/self-harm walk through occurs annually, is documented in the Self Harm Facility Inspection Tool, and documented recommendations are made to leadership.
• Maintain the Self-Harm and Restraint Tracking tools for both the North and South Campuses.
• Perform other duties as assigned.

Requirements

Preferred

• 3+ years of experience in healthcare, behavioral health, residential treatment, compliance, quality assurance, risk management, or a related field.
• Working knowledge of State of Utah licensing requirements applicable to behavioral health and residential treatment programs.
• Demonstrated experience conducting compliance audits, chart reviews, quality assurance reviews, or regulatory inspections.
• Strong understanding of clinical documentation standards, HIPAA, incident reporting, and healthcare compliance requirements.
• Experience working with insurance payors, credentialing, audits, recoupments, or claims documentation.
• Demonstrated ability to investigate incidents, identify root causes, develop corrective action plans, and follow through on remediation.
• Experience developing and delivering staff training related to compliance, safety, documentation, policies, or regulatory requirements.
• Strong organizational skills with the ability to manage multiple regulatory deadlines, inspections, audits, renewals, and compliance projects simultaneously.
• Demonstrated ability to interpret regulations, accreditation standards, policies, and contractual requirements and translate them into practical operational expectations.
• Ability to work effectively with clinical, direct-care, administrative, maintenance, HR, billing, and executive leadership teams.
• Strong attention to detail and ability to identify gaps, inconsistencies, and potential compliance risks.
• Ability to maintain confidentiality and appropriately handle sensitive clinical, personnel, legal, and incident-related information.
• Ability to respond effectively to urgent compliance issues, critical incidents, regulatory inquiries, and short-notice audits or inspections.
• Must successfully pass all required background checks and meet all applicable licensing and employment requirements.