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About the role
Key responsibilities & impact- Oversee adherence to the Company’s compliance program using OIG Compliance Program Guidance for Third-Party Medical Billing Companies
- Assist the General Counsel in implementing and leading the Company’s compliance committee
- Improve efficiency and quality of services and reduce vulnerability to fraud, abuse, waste, and other risks
- Investigate, review, and respond to compliance issues, concerns, and complaints
- Review governmental health plan publications and arrange training about relevant changes
- Revise the compliance program in light of changes in company needs, laws, and payer policies
- Review employee certifications and standards-of-conduct compliance
- Develop, coordinate, and participate in compliance education and training programs
- Coordinate personnel and provider screening against the Cumulative Sanction Report
- Coordinate internal compliance reviews and monitor departmental activities
- Design and coordinate internal investigations and corrective actions
- Develop policies encouraging reporting of suspected fraud and improprieties without retaliation
- Process Medicare pre- and post-payment audits
- Process patient complaints and disputes involving possible compliance or provider service problems
- Research and develop answers to coding or billing situations with the Vice President of Strategy and Integrity
- Establish and perform internal reimbursement-coding audits
- Report internal audit findings to leadership bi-monthly
- Track error rates and ensure improvement or outline further steps
- Provide pertinent new and deleted CPT code lists for client fee schedule updates
- Troubleshoot coding issues for business associates and internal personnel
- Communicate with payers regarding prepayment review resolution
- Review accounts and determine resolution methods for prepayment reviews
- Provide quarterly compliance training on new issues and identified deficiencies
- Assist with training and troubleshooting for payment deficiencies
- Manage payer appeals specialist
Requirements
What you’ll need- Undergraduate degree in related field preferred
- Extensive knowledge of ICD10-CM and CPT coding principles and guidelines
- Extensive knowledge of federal regulations and policies pertaining to physician documentation, coding, and billing
- 4+ years coding experience
- 3+ years auditing experience
- 1-2 years supervisory experience
- Ability to exercise judgment and propose courses of action where precedent may not exist
- Experience in medical billing and compliance in healthcare preferred
- Manages payer appeals specialist