Medical Billing Compliance Manager

This is a fully remote position, open to applicants in California.

📋 Description

• Supervise the adherence to the Company’s compliance program in accordance with OIG Compliance Program Guidance for Third-Party Medical Billing Companies.

• Support the General Counsel in implementing and leading the Company’s compliance committee.

• Enhance the efficiency and quality of services while minimizing exposure to fraud, abuse, waste, and other risks.

• Investigate, assess, and address compliance issues, concerns, and complaints.

• Analyze governmental health plan publications and organize training on relevant updates.

• Update the compliance program in response to changes in company requirements, laws, and payer policies.

• Evaluate employee certifications and adherence to standards of conduct.

• Create, coordinate, and participate in compliance education and training initiatives.

• Coordinate personnel and provider screenings against the Cumulative Sanction Report.

• Oversee internal compliance reviews and monitor departmental operations.

• Design and manage internal investigations and corrective measures.

• Develop policies that promote the reporting of suspected fraud and misconduct without fear of retaliation.

• Handle Medicare pre- and post-payment audits.

• Address patient complaints and disputes related to potential compliance or provider service issues.

• Research and formulate responses to coding or billing scenarios in collaboration with the Vice President of Strategy and Integrity.

• Establish and conduct internal reimbursement coding audits.

• Present internal audit findings to leadership every two months.

• Monitor error rates and ensure improvement or recommend further actions.

• Provide relevant new and removed CPT code lists for client fee schedule updates.

• Resolve coding issues for business associates and internal staff.

• Communicate with payers regarding resolution of prepayment reviews.

• Review accounts and determine resolution strategies for prepayment reviews.

• Deliver quarterly compliance training on emerging issues and identified shortcomings.

• Assist with training and troubleshooting related to payment deficiencies.

• Oversee the payer appeals specialist.

⛳️ Requirements

• Bachelor's degree in a related field is preferred.

• In-depth knowledge of ICD10-CM and CPT coding principles and guidelines.

• Comprehensive understanding of federal regulations and policies regarding physician documentation, coding, and billing.

• A minimum of 4 years of coding experience.

• At least 3 years of auditing experience.

• 1-2 years of supervisory experience.

• Ability to exercise judgment and suggest actions in situations where no precedent exists.

• Experience in medical billing and compliance within the healthcare sector is preferred.

• Responsible for managing the payer appeals specialist.

🏝️ Benefits

• Competitive salary and performance-based bonuses.

• Comprehensive health benefits including medical, dental, and vision coverage.

• Opportunities for professional development and continuous education.

• Supportive work environment with a focus on work-life balance.