Compliance Manager

Brault • San Dimas, CA

3d • $110,000 - $125,000

About The Position

The Compliance Manager ensures that the Company, its officers and management, employees, business associates, and, to the extent possible, clients understand and adhere to applicable government laws, regulations, policies, and procedures. The role oversees the Company’s compliance program, guided by the OIG Compliance Program Guidance for Third-Party Medical Billing Companies and tailored to the Company’s needs. It also investigates compliance issues, supports internal audits and corrective actions, coordinates training, and addresses coding, billing, payer review, and patient complaint matters.

The Compliance Manager assists the General Counsel with establishing and leading the Company’s compliance committee and coordinates with Human Resources, Provider Enrollment, operations managers, business associates, and internal personnel. The role manages the payer appeals specialist and reports internal reimbursement-coding audit findings to leadership bi-monthly.

Requirements

• Excellent organizational skills.
• Excellent written and oral communication skills.
• Excellent analytical skills.
• Extensive knowledge of ICD-10-CM and CPT coding principles and guidelines.
• Extensive knowledge of federal regulations and policies pertaining to physician documentation, coding, and billing.
• At least 4 years of coding experience.
• At least 3 years of auditing experience.
• 1–2 years of supervisory experience.
• Ability to exercise judgment and propose courses of action where precedent may not exist.

Nice To Haves

• Undergraduate degree in a related field preferred.
• Experience in medical billing and healthcare compliance preferred.

Responsibilities

• Oversee adherence to the Company’s compliance program, using OIG guidance for third-party medical billing companies as a guide adapted to the Company’s needs.
• Assist the General Counsel in implementing a compliance committee and lead and conduct its meetings.
• Develop methods to improve efficiency and service quality and reduce vulnerability to fraud, abuse, waste, and other risks.
• Investigate, review, and respond to compliance-related issues, concerns, and complaints from employees, regulators, health plans, clients, and other sources.
• Review governmental health plan publications and circulate relevant changes or arrange related training.
• Periodically revise the compliance program to reflect changes in Company needs and government and private payor laws, policies, and procedures.
• Review employee certifications and ensure employees receive, read, and understand the standards of conduct.
• Develop, coordinate, and participate in compliance education and training for appropriate employees and management.
• Coordinate personnel issues with the Vice President of Human Resources to help ensure employees do not appear in the Cumulative Sanction Report.
• Coordinate with the Manager of Provider Enrollment to help ensure providers do not appear in the Cumulative Sanction Report.
• Assist operations managers with coordinating internal compliance reviews and monitoring, including annual or periodic departmental reviews.
• Independently investigate and act on compliance matters; design and coordinate internal investigations and corrective actions with billing departments, providers, sub-providers, agents, and, where appropriate, independent contractors.
• Develop policies and programs that encourage reporting suspected fraud and other improprieties without fear of retaliation.
• Process Medicare pre- and post-payment audits.
• Process patient complaints or disputes involving possible compliance or provider service problems.
• Consult with the Vice President of Strategy and Integrity to research and develop answers to difficult or unclear coding and billing situations in accordance with government laws and regulations.
• Assist in establishing and performing internal reimbursement-coding audits; report findings to leadership bi-monthly, track error rates below acceptable levels, and ensure improvement or identify further steps with the relevant Executive Director.
• Provide lists of pertinent new and deleted CPT codes annually when the revised CPT manual becomes available, for use in updating client fee schedules.
• Assist business associates and internal personnel with coding issue troubleshooting.
• Communicate with payers to resolve prepayment reviews; review accounts to assess the merits of reviews, identify resolution methods, and engage internal personnel as needed.
• Provide quarterly compliance training on new issues or identified deficiencies.
• Assist with training and troubleshooting for payment deficiencies.
• Manage the payer appeals specialist.
• Perform other duties as assigned; duties and responsibilities may change with or without notice.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: No Education Listed