Provider-Based Billing Compliance and Revenue Optimization Specialist

VCU Health • Richmond, VA

14h

About The Position

The Provider‑Based Billing (PBB) Compliance & Optimization Specialist is independently responsible for ensuring organizational compliance, audit readiness, revenue integrity, and operational effectiveness align with provider‑based requirements defined in 42 CFR §413.65 of the Federal Registry. The Specialist reports directly to the VCUH Revenue Cycle Optimization Director and provides leadership, education, and accountability for program development, implementation, and continuous improvement within its area of responsibility.

Requirements

• Bachelor’s degree in healthcare administration, business, finance, or related field, or equivalent experience in a field related to compliance with provider-based requirements and billing. Combination of education and experience may be considered in lieu of a degree.
• Minimum 5 years of experience in revenue cycle, reimbursement, or compliance within a healthcare environment
• Demonstrated experience interpreting and implementing federal regulations
• Experience conducting root cause analysis and performance improvement activities
• Experience conducting audits of revenue cycle workflows and billing system build to ensure compliance with regulations
• Strong analytical skills, including financial analysis, variance investigation, and data interpretation.
• Experience working with Epic.
• Experience with Microsoft Word, Excel, PowerPoint, Teams
• Exceptional written and verbal communication skills.
• Ability to translate complex rules into practical workflows.
• Strong critical thinking and problem-solving abilities.
• Comfort leading cross-functional initiatives with diverse teams.
• Proactive, self-directed, and highly organized.

Nice To Haves

• Epic Certification in PB/HB, Prelude, Cadence, or Resolute.

Responsibilities

• Regulatory & Compliance Oversight: Independently determine PBB eligibility for new and existing clinic locations through financial, administrative, and operational integration assessments. Lead completion of CMS PBB Attestation for all hospital-owned clinics and facilities, and ensure audit-ready documentation, including ownership evidence, integration details, organizational charts, and shared service descriptions for all hospital clinics and facilities. Conduct scheduled annual compliance reviews to ensure continued compliance with CMS regulations. Validate the accuracy of PECOS enrollment for all hospital facilities and ensure alignment of provider-based designation with CMS Cost Reporting and Pharmacy 340B submissions. Monitor regulatory updates, assess organizational impact, and communicate changes to key stakeholders.
• Financial & Revenue Cycle Analysis: Conduct financial modeling for PBB conversions, estimating facility fee revenue and payer-specific reimbursement. Analyze expected vs. actual revenue performance for all PBB locations and identify root causes of variances. Develop recurring reports and dashboards to track financial performance trends across the PBB portfolio. Facilitate cross-functional Medicare HB Reconciliation Workgroup to identify root cause and resolve hospital billing issues related to provider-based billing. Collaborate with Finance, Revenue Integrity, and Ambulatory Operations to validate assumptions and ensure accurate financial forecasting.
• EHR & Billing Systems Accuracy: Responsible for the accuracy of Epic configuration requirements for PBB designation, acting as the central liaison between Operations, Finance, Revenue Cycle, and IT. Conduct routine audits to ensure correct utilization of PBB logic across all visits, providers, and departments. Monitor Epic system changes that may affect PBB rule setup and engage stakeholders to evaluate the impact. Test new clinic builds before go-live, including end-to-end revenue cycle testing. Serve as escalation contact for PBB issues that may indicate setup problems or compliance gaps.
• Facility/Provider Enrollment & Location Management: Work closely with Credentialing and Enrollment teams to validate the accuracy of CMS PECOS enrollment for all hospital-based clinics, ensuring proper ownership, location details, and taxonomy alignment. Coordinate PECOS changes for new sites, relocations, closures, and mobile units. Maintain a master registry of all facility locations, including PBB status, addresses, CCNs, NPIs, and Epic location IDs. Ensure consistency across PECOS, NPPES, Epic, and payer credentialing databases to prevent billing errors and ensure compliance.
• Governance & Committee Leadership: Serve as the lead advisor for provider-based billing to leadership and key committees. Develop and maintain standards for policies, documentation requirements, Epic configurations, and compliance monitoring for adding, modifying, and assessing provider-based billing locations. Develop and deliver training about provider-based billing requirements and impact across operational, clinical, finance, and revenue cycle teams. Present risks, trends, and revenue opportunities to leadership. Coordinate cross‑functional efforts with Compliance, Finance, Ambulatory, Legal, IT, and Revenue Cycle to ensure consistent and compliant provider-based billing practices.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level