Manager, Physician Practices and Ambulatory Care Compliance

Hackensack Meridian Health•Iselin, NJ

1d•Hybrid

About The Position

The Compliance Manager for Physician Practices and Ambulatory Care is responsible for the development, implementation, and oversight of the compliance program for the organization's physician practices and affiliated ambulatory care services. This position ensures the integrity of the practice's regulatory environment by actively monitoring changes in healthcare laws and regulations. The manager will proactively research, investigate, and respond to issues related to documentation, coding, billing, and licensure. This role is critical in assuring compliance with all payer and regulatory requirements, including but not limited to those of Medicare, Medicaid, and applicable state laws.

Requirements

Bachelor's degree in Healthcare Administration, Business Administration, or a related field.
Minimum of 5-7 years of experience in healthcare compliance, with significant experience in auditing, coding, and physician practice/ambulatory care settings.
In-depth knowledge of federal and state healthcare regulations, including Stark Law, Anti-Kickback Statute, and HIPAA.
Proficiency with ICD-10 and CPT-4 coding methodologies, physician documentation, and reimbursement principles.
Demonstrated experience in developing and implementing compliance programs, conducting audits, and leading investigations.
Proficiency in the use of electronic health records (EHRs), preferably Epic Ambulatory.
Strong analytical, problem-solving, and project management skills.
Excellent interpersonal, presentation, and written communication skills.
High degree of professionalism, integrity, and ability to work collaboratively with physicians, staff, and leadership.
Proficient computer skills that include but are not limited to Google Suite and/or Microsoft Office platforms.

Nice To Haves

Familiarity with The Joint Commission (TJC), state Department of Health, and CMS regulations.
Proficiency in Epic Ambulatory.
Certification in Healthcare Compliance (CHC).
A coding credential (e.g., CPC, CCS).

Responsibilities

Performs and oversees retrospective and concurrent audits and performance improvement reviews to ensure compliance with regulatory and payer requirements.
In partnership with the Deputy Chief Compliance Officer, manages staff auditors.
Reviews physician and advanced practice provider documentation in the medical record for appropriateness and to ensure that billing is reflective of the services provided.
Reviews medical records to assess appropriate ICD-10 and CPT-4 assignment for Medicare, Medicaid, and commercial payers for reimbursement purposes.
Develops, implements, and maintains an effective compliance program, including policies, procedures, and a compliance manual for physician practices and ambulatory care.
Maintains current knowledge of payer and regulatory requirements, including federal and state laws such as the Stark Law and Anti-Kickback Statute.
Develops content and conducts ongoing compliance training and education for physicians, management, and staff on relevant laws, regulations, and identified risk areas.
Facilitates the timely submission of accurate claims through daily interaction with practice leadership, physicians, coders, and the Physician Billing Department.
Monitors all aspects of the revenue cycle to ensure compliant reimbursement and provides reports to leadership as needed.
Manages and conducts investigations into compliance-related concerns, ensuring timely and thorough resolution.
Serves as an active participant in workflow development within the practice and the Electronic Health Record to ensure compliant documentation and billing.
Acts as a liaison to the Physician Billing Department and any external coding or billing services, maintaining open lines of communication.
Prepares and presents regular reports to the Deputy Chief Compliance Officer and Compliance Committee on program status, audit findings, and investigative matters.
Other duties and/or projects as assigned.
Adheres to HMH Organizational competencies and standards of behavior.