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Description

Job Summary

Responsible for the oversight and management of auditing and monitoring activities, policies and procedures, risk assessments, and development of risk-based educational materials to ensure compliance with federal/state laws and regulations, and Nicklaus Children's policies. Responsibility involves the management of three (3) billing compliance personnel, workflow analysis, productivity, auditing, quality review, problem resolution, and hands on supervision.

Job Specific Duties

• Provide oversight on billing compliance auditing, monitoring, and educational activities within the compliance department.
• Create audit schedules and manage workflows to adhere to the audit schedule.
• Oversee and supervise billing compliance personnel, including work allocation, production expectations, training, quality of work performance, and implement corrective action plans to improve performance, if needed.  
• Develop methods to effectively communicate information through presentations, graphs, reports, educational materials, etc.  
• Develop, establish, and review policies and objectives consistent with those of the organization to ensure efficient departmental operations.
• Conduct DRG validation (clinical/coding) audits to determine accuracy of billing through verification of coding and supporting clinical documentation. 
• Consult and seek guidance and direction from the compliance directors and/or Chief Compliance Officer as necessary. 
• Review, assesses, study, and analyze the overall coding, billing, documentation and reimbursement system for potential compliance problems. 
• Serve as a point of contact for reports of billing compliance concerns or potential issues. Respond timely and professionally. 
• Support the development and rollout of billing compliance educational materials and provide in-person or on-line training as needed.
• Investigate billing compliance matters filed with regulatory agencies at the direction of the compliance directors and/or Chief Compliance Officer. 
• Conduct and/or manage special projects to include due diligence audits, government and payer audit investigations and queries, including, Recovery Audit Contractors (RAC) and Medicaid Integrity Program Contractors.
• Maintain current knowledge of changes in federal and state coding and billing regulations/guidelines and ensure staff is kept informed. 
• Perform special audits and other duties as assigned.  

Qualifications

Minimum Job Requirements

• Bachelor's Degree in Healthcare Administration, Business, or related field
• Certified Inpatient Coder (CIC) required upon hire
• Certified in Healthcare Compliance and/or other Coder certifications - Hospital Fee and Professional Fee (e.g., CPMA, CPC, CCS, RHIT) required within one year in position.
• 4-7 years Experienced in billing compliance, medical coding, or other relevant experience
• 4-7 years Supervisor experience in compliance coding/billing audits
• Healthcare provider/payer experience
• Complex investigation and audit experience

Knowledge, Skills, and Abilities

• Thorough knowledge and understanding of diagnosis-related group (DRGs) and overall hospital billing, coding, and documentation.
• Knowledge and understanding of Centers for Medicare and Medicaid Services (CMS) guidelines.
• Ability to maintain highest level of confidentiality.
• Ability to follow-through, meet regulatory deadlines, and anticipate.
• Ability to lead in a team environment with minimal supervision.
• Strong analytical and problem-solving skills.
• Excellent time management and organization skills.
• Able to use considerable use of tact, diplomacy, discretion, and judgment.
• Systems knowledge of Cerner.
• Effective training and presentation skills.
• Knowledge of Federal and State regulations related to healthcare billing compliance.
  

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