Department Spotlight: Audit & Compliance

Nov. 3-7 is National Compliance & Ethics Week! Celebrate with us by getting to know the Audit & Compliance team at Renown Health and Hometown Health.

Take a moment to think about the complex web of healthcare beyond the frontlines. More specifically, let’s zero in on the long list of regulations and processes that every hospital and health system across the country needs to follow. Sounds a bit intimidating to the average person, right? And as the only not-for-profit academic health system in the region, integrity and ethics is not something we cut corners on. So, who can make sense of it all so that our health system stays strong, transparent and trustworthy?

This is our Audit & Compliance department’s time to shine. This intelligent, fast-acting group of compliance specialists and analytics, coding and internal auditors and audit managers, billing compliance coordinators, special investigators, oversight coordinators and more help bridge the gap between ethical practices and the constant demands of a large health system like Renown. Although their work often takes place behind the scenes, the impact of this team can be felt throughout every corner of our network.

Our In-House Health System Lifeguards

The Audit & Compliance team at Renown and Hometown Health is a dedicated partner in safeguarding the integrity of our health system and supporting both our care teams and patients. Think about it this way: they handle all those complicated requirements on the backend so that the healers can keep on healing.

So, let’s break down some of their main duties (hint: there’s never a dull moment in Audit & Compliance!):

• Identifying risks and handling risk assessments
• Monitoring new and existing regulations
• Reviewing and auditing processes
• Managing investigations related to HIPAA, conflicts of interest, physician compensation and allegations of compliance policy violations
• Collaborating closely with our Human Resources, Risk Management, Patient Experience, Quality and Legal departments

“The work of the Audit & Compliance department is in support of the patients, caregivers, providers and those who support them to ensure Renown Health remains compliant with all federal and state healthcare rules and regulations,” said Mark N., Chief Compliance Officer. “We handle all hotline call activity, internally reported concerns and issues identified by risk assessments and audits. No two days are the same.”

“A day in the life of Audit & Compliance varies depending on whether we’re in audit season or not,” added Michelle B., Compliance Analyst. “During audit season, things move fast—emails are constantly flying back and forth with questions, file requests, status updates and more. On top of that, we’re handling member incidents, conducting investigations and responding to inquiries. We jokingly refer to ourselves as the Hometown Health Fire Department! Outside of audit season, the pace doesn’t slow down much. We’re still researching and answering complex questions, reviewing new regulations, distributing health plan management system memos to the appropriate teams and tracking attestation deadlines. We also stay on top of annual Corrective Action Plans to ensure that any previous audit findings have been fully addressed.”

Shining a spotlight on the Compliance side of things, these masters of ethics handle work plans, policies and procedures, operational risk assessments, documentation and disclosure reviews, concerns and complaints, and even HIPAA and Compliance classes.

“In a single day, everybody on our team does a variety of different things, and each of us has expertise in different areas of Compliance,” said Nicole G., Senior Compliance Specialist. “For me, a day can include receiving or following up on patient complaints and inquiries, working with leaders throughout the organization to help answer questions or develop processes that may have Compliance implications or giving a presentation about different Compliance topics. So much of our work happens behind the scenes, but our goal is to ensure that Compliance is embedded in our policies and procedures throughout the organization so that staff providing patient care know that their actions are both ethical and compliant.”

“A typical day in my life as a Compliance Specialist involves reviewing any employee, outside agency, individual and patient reported compliance concern,” added Tara B., Compliance Specialist. “We work closely with every department throughout the health system, reviewing policies, contracts, billing and patient communications for regulatory compliance. In a typical day we may investigate a report that someone looked into a patient’s chart without a business need, a conflict-of-interest report, a spam text message or a social media post.”

“A day in the life for health plan compliance consists of collaborating with leaders to ensure regulations are understood and followed and any issues identified are remediated as soon as possible,” added Lenee Linzey, Director of Compliance for Hometown Health. “Our priority is always to identify and remediate any negative member impact like delays to accessing care or increased out of pocket costs.”

Shifting our focus over to the Audit side, these rulers of risk help departments improve how they operate, focusing on processes, risks and controlling those risks. They ensure everyone is doing the job they should with the least amount of risk possible, supporting safe and ethical patient care.

“The focus of our work is to look at business processes and look at what employees are doing to follow them, then evaluating if the processes are done compliantly, effectively and with the right number of controls to reduce variability and risk,” said Ashlynn M., Internal Audit Manager. “Our goal is to give an objective look into processes to ensure they meet the goals of the unit, and therefore, the goals of Renown. Most of our days are spent conducting the audit process, interviewing employees, conducting research of audit tools and department functions, documenting all parts of the audit process and more. It is way more fun than it sounds.”

“My day as an internal auditor involves a mix of research, analysis and collaboration,” added Elizabeth M., Internal Auditor. “I work with teams across the organization to review processes, identify risks and ensure compliance with laws and policies. Our work ensures that every decision and process is aligned with doing the right thing for our patients and the community.”

“I manage many different coding audits for government payers,” added Heidi F., Manager of Internal Audit & Coding. “Auditing ensures that the patients receive correct billing information as we validate to ensure the coding is correct. It also ensures that the facility is receiving the correct reimbursement, and the patients are being billed correctly for the care that has been received.”

But wait, there’s more. This department has a few unique roles, filled by dedicated individuals who serve as our oversight experts. They help ensure health system efficiency stays in tip-top shape, and no fraud creeps through our hospital doors.

“A day in the life of a Fraud Waste Abuse investigator involves reviewing claims, medical records and data for irregularities,” said Courtney J., Special Investigations Unit Investigator. “By ensuring billing is accurate and resources are not wasted, I help protect funds that go back into patient care, making sure services stay accessible and affordable for the people who need them.”

“My work as a Delegation Oversight Coordinator changes daily; of course, there are some pieces of the puzzle that remain the same but reviewing the compliance of our delegated entities through audits, assessments and communication of business owners is ever changing,” added Crystal B., Delegation Oversight Coordinator. “Through delegation oversight, I help to ensure that those businesses we delegate work to follow all state, federal and accreditation rules and regulations. This work ensures that our members receive the best of care under the most up to date guidance.”

After digesting all of this, it’s important to remember that the acts of compliance and audit aren't about catching people doing something wrong; they're about building trust between the patient, the provider and the community. This team's willingness to be available and approachable to anyone is what they do best to make patient care possible.

“In Audit & Compliance, we operate at an organization-wide level down to the individual,” said Tobriah H., Senior Compliance Analyst. “While we have tasks throughout the year to strengthen the organization's ability to comply with laws and regulatory matters, we also work on investigations and respond to inquiries daily when concerns are presented. So, while we have this 10,000-foot view, we also work at the granular level to obtain precise details when it comes to a specific inquiry or investigation.”

“We help provide the framework to deliver safe, ethical care every day, and the assurance that our patients, staff and community can count on Renown to do the right thing, even when no one is watching,” added Ebony D., Compliance Specialist. “We help turn our values into daily actions that honor and protect our patients.”

Adept and Accomplished

Work hard, play hard and reap the rewards – and on the Audit & Compliance team, those rewards are always rolling in thanks to their diligence and guidance in creating a culture where doing the right thing is always top-of-mind.

“There have been many accomplishments that improved compliance and audit processes or helped reduce risk, but I am most proud of how the Audit & Compliance team members work together to solve problems, create solutions and support one another,” said Mark N. “I can feel the positive energy and the consistent desire to help others and always do the right thing. I am beyond fortunate and honored to lead this amazing team.”

“Promoting and supporting ethical behavior is a major focus of our team, and we have found that a great way to accomplish that is to build bridges with the operational teams to keep lines of communication open so that we can help to guide them in compliant and ethical behavior,” added Bob W., Governance Risk & Compliance Specialist.

Over the past year, the Audit & Compliance team has made significant strides in strengthening its presence across Renown. Through a focus on collaboration, transparency and proactive communication, the team is seen as a visible, trusted partner in organizational operations.

“I am most proud of the increased level of visibility our team has achieved throughout the organization over the last year and the relationships that formed as a result,” said Marcie D., Senior Compliance Specialist. “Now we have a strong, core team of Compliance Specialists who routinely round in all locations, including every inpatient unit, to make sure our team members know who we are and that we are their partners in creating the best possible environment for them and our patients. There’s a big difference in the responses of ‘Oh, no! Compliance is here,’ and ‘Hey, Compliance is here! Let’s ask them about x-y-and z.’ We work hard every day to make sure it’s the latter.”

“I am most proud of having such a collaborative team,” added Nix T., Coordinator of Billing Compliance. “We are all highly functioning in our Audit & Compliance individual specialty, but when we work together as a group, it is like watching a musical symphony. We are here to help guide the organization so that we can rest easy knowing we are functioning as a business ethically and serving our community responsibly.”

But no accomplishment reigns supreme over the team itself, according to this department. As role models of Renown’s mission, vision and values – especially Integrity and Collaboration – these team members are especially proud of the village they’ve built.

“We have conducted a high number of internal audits and follow ups; ensured our first tier, downstream and related entities (FDR) are compliant; hired a new special investigations unit investigator; and have overseen and managed a range of regulatory updates,” said Ed C., Compliance Analyst. “As a team, we have managed to accomplish all this sometimes under uncertainty. Our greatest accomplishment is our team itself.”

“When we started up Renown’s Internal Audit team again two years ago, a lot of program development had to happen to make it a value add,” added Ashlynn M. “Over the past year, the Institute of Internal Auditors revised their audit standards, so we spent a considerable amount of time developing our program to align with these new standards. This included revising our charter, creating a strategic plan, and revising policy/procedure and the audit process. We completed all that in addition to audits and collaborating with great people throughout Renown.”

Those accomplishments translate over to the Hometown Health side of this team as well, practicing expert collaboration to make sure the insurance arm of Renown continues to function at the best of its ability.

“The Audit & Compliance team at Hometown Health has made significant contributions behind the scenes,” said Michelle B. “One standout achievement was the policy revision to align with NCQA standards—a major undertaking that required close collaboration and attention to detail. Every effort contributes to our shared goal of maintaining a 4.5-star rating, and that truly means something to all of us.”

“As a team that works with every department within Hometown Health, we have accomplished so much to keep us in line with regulations,” added Crystal B. “We worked hard over the last year on policy alignment, providing reports and data to state regulators and ensuring new guidance was distributed as needed. To do this, the Compliance team communicated at every step in the process. I am most proud of how Hometown Compliance continues to work well as a team year after year.”

By working hand-in-hand with each other and all departments across our health system, the Audit & Compliance team has helped create a culture where accountability and collaboration thrive.

“Integrity in small things leads to trust in big things,” said Mark N. “We want to exceed expectations in all that we do.”

A Career That Chooses You

So, how did these devoted team members end up choosing a career in Audit & Compliance?

Well, that’s a bit of a trick question: for most of these employees, the career field, in a sense, chose them.

“Most people who end up in Audit & Compliance don't choose it; it chooses them,” said Ashlynn M.

“Compliance chose me when I started my career with the State of Nevada in 2012,” added Heidi F. “I enjoy auditing and compliance tasks.”

Everyone’s journey to the Audit & Compliance department is unique. Although their backgrounds are different, their shared goals and passions remain the same.

From the legal world...

“I started out wanting to be a paralegal and I was working as an office manager for a physician practice when I was hired by an insurance company and gravitated compliance due to my ability to analyze laws and write letters to DOI and lawyers,” said Russell D., Senior Compliance Analyst.

“I have a background in the legal field and was initially employed at another health system as a legal assistant and contracts administrator,” added Tobriah H. “I worked closely with the physician compensation team, reviewing and drafting contracts for physician arrangements, which required that I become familiar with Stark law, sparking that initial interest in all things Compliance.”

“My background has always been rooted in investigations and oversight,” added Courtney J. “I started my career in roles focused on healthcare fraud, waste and abuse. I built skills in reviewing complex cases, analyzing data and ensuring regulations were followed. Over time, I realized I enjoyed the balance of protecting organizations while also helping them operate more effectively. Having a career in audit and compliance allows me to use my investigative skills in a proactive way, making sure processes are sound, risks are managed and standards are met.”

...to an inspiring and diverse undergraduate education...

“As a new hire, what brought me to Renown Health was policy; my undergraduate and graduate degrees are in public policy, and I wanted a career that involves research, creation and implementation of all things policy,” said Ebony D. “Renown’s commitment to improving the health and well-being of the community through their innovative policies and programs really resonated with me. The opportunity to work on meaningful policies that have a direct impact on people's lives is what keeps me motivated and excited to come to work every day. I am grateful to be part of a team that values my background and experience with policy, and I look forward to contributing to Renown’s mission in the years to come.”

“During my undergraduate studies, I pursued a minor in fraud examination, which introduced me to the world of internal audits,” added Elizabeth M. “In my capstone course, a professor shared an opportunity for an internal audit internship at a local utilities company. That experience sparked my passion for investigative work and problem-solving. I realized that Audit allows me to ask meaningful questions, highlight new efficiencies and help organizations operate with integrity.”

...to local and state government...

“I started out as a file clerk in insurance verification and from there over the years I performed the duties of insurance verification, registration, financial counseling, county and state billing and more, eventually becoming a Supervisor over Government Programs and then Manager of the Business Office and Patient Access,” said Sue S., Coordinator of Billing Compliance. “In 1999, Renown started developing an internal billing compliance coordinator role. Since compliant billing was always a requirement, especially for government billing, this was a great opportunity for me to continue doing what I loved: Medicare regulations and education.”

“Prior to working at Hometown Health, I worked for the State of Nevada as the Quality Auditor providing fiscal and regulatory oversight of the state's national school lunch and breakfast program,” added Ed C. “When I was at the State of Nevada, the regulatory program did not exist. Working with my peers and manager, we created the program that aligned the state with the requirements in the Healthy, Hunger Free Kids Act. I was here for nearly five years, and over that time I began direct collaboration and provided training for our federal peers at the U.S. Department of Agriculture. This allowed me to use the full range of my abilities. I loved the flexibility that this field provides.”

...and to the lab and hospital itself.

“As stated, I came to Renown to work in the Laboratory,” said Marcie D. “I had no intention of leaving the Lab until 2017, when Risk Management asked me to consider joining their team. It sounded like an amazing opportunity to grow my skills and form relationships with people I would not usually encounter, so I decided to go for it. Risk and Compliance cross paths routinely in our organization, but the work in Compliance is so different that it seemed like the next logical step: I would have the chance to obtain new skills and knowledge, while taking on a different role in terms of how we interact with our patients, employees and providers. And best of all – I would still be able to call Renown ‘home’ while having the flexibility I needed for my family.”

Now, why bring their skills to Renown and Hometown Health? Well, according to the team, there are a lot of different reasons! We asked them to fill in their thoughts and feelings in response to this prompt: “I chose to work for Renown and Hometown Health because...”

• “...of the strong community presence and the potential for personal growth within healthcare; I stay because I have a wonderful team and leaders that I love working with and the learning opportunities are seemingly endless.” - Nicole G.
• “...I was drawn to the locally owned not-for-profit organization and its mission of putting patients and the community first. Hometown Health in particular stood out to me as a local health plan that is deeply committed to improving access, affordability and wellness for families in the community. I stay because of the culture and the people. I feel supported by leadership and colleagues who are passionate about making a difference every day.” - Courtney J.
• “...of its reputation for putting people first, both in the community and within the organization. From the start, I was drawn to the culture of compassion and care. What has kept me here is the opportunity to contribute to a growing internal audit program that's committed to continuous improvement and making a meaningful impact on patient care.” - Elizabeth M.
• “...Renown has always been my go-to for healthcare services, and the exceptional care and positive culture inspired me to apply—I wanted to be part of the experience I had always appreciated. I chose to apply to Hometown Health not only because of the position, but because I felt drawn to the strong sense of community. When we were all working together in the building, it truly felt like a family. We laughed, collaborated and even played games from time to time. It was, and continues to be, a fun and fulfilling environment.” - Michelle B.
• “...I love being part of an organization that is passionate about helping people and improving their lives.” - Bob W.

In every audit, review and conversation, the Audit & Compliance department reinforces our shared commitment to excellence and to caring for our community – the right way.

“This team exemplifies integrity and service excellence in its work with employees and patients. I am thankful to be part of a team that works collaboratively, treats others with respect and is willing to help each other as well as other departments. We have amazing leadership that values our input, education and experience. We are mentored to grow and learn and have a true work-life balance. And we are a fun group! Come visit us for a day and learn about what we do,” closes Tara B.