Job Description

Position Summary

The Compliance Manager has the responsibility to assure that the Company, its officers and management, its employees, its business associates and, to the extent possible, its clients are informed about and adhere to the letter and intent of applicable government law, regulations, policy and procedures.

Essential Duties and Responsibilities

• Oversees the adherence to the Company’s compliance program using the OIG Compliance Program Guidance for Third-Party Medical Billing Companies as a guide modified to meet the Company’s unique needs.
• Assist the General Counsel in implementing a compliance committee within the Company and lead and conduct all meetings.
• Establishes methods to improve the Company’s efficiency and quality of services and to reduce the company’s vulnerability to fraud, abuse and waste, and any other potential risks.
• Responsible for investigating, reviewing and responding to any and all compliance related issues, concerns and complaints brought to the department from any and all sources, including but not limited to, employees, Federal and State regulatory bodies, health plans and clients.
• Reviews all pertinent governmental health plan publications as they are published. Circulate, or arrange for training about, changes or additions relevant to the Company, its industry and its clients.
• Periodically revise the compliance program in light of changes in the Company’s needs and in the law and policies and procedures of Government and private payor health plans.
• Reviews employees’ certifications and ensures that they have received, read, and understood the standards of conduct.
• Develops, coordinates, and participates in a multifaceted educational and training program that focuses on the elements of the compliance program and seeks to ensure that all appropriate employees and management are knowledgeable of, and comply with, pertinent Federal and State standards.
• Coordinates personnel issues with the Vice President of Human Resources to ensure that employees do not appear in the Cumulative Sanction Report
• Coordinates with the Manager of Provider Enrollment to ensure that providers do not appear in the Cumulative Sanction Report.
• Assists the company’s operation managers in coordinating internal compliance review and monitors activities, including annual or periodic reviews of departments.
• Independently investigates and acts on matters related to compliance, including the flexibility to design and coordinate internal investigations (e.g. responding to reports of problems or suspected violations) and any resulting corrective action with all billing departments, providers and sub-providers, agents, and, if appropriate, independent contractors.
• Develops policies and programs that encourage managers and employees to report suspected fraud and other improprieties without fear of retaliation.

Operational Responsibilities

• Process Medicare pre- and post-payment audits
• Process patient complaints/disputes that address possible compliance or provider service problems
• Consult with Vice President of Strategy and Integrity to research and develop answers to difficult or confusing coding or billing situations to comply with government laws and regulations
• Assist, establish and perform an internal reimbursement-coding audit. Provide Leadership with a report of the findings of the internal audit bi-monthly. Track below acceptable error rates (through formal reporting mechanisms) and ensure improvement or outline further steps to be taken in conjunction with the Executive Director of the respective department.
• Annually when the revised CPT manual is available, provide lists of pertinent new and deleted CPT codes for use to update current client fee schedules
• Assist business associates and internal personnel with trouble-shooting coding issues.
• Communicate with payers regarding resolution of prepayment reviews. Review accounts to determine whether the prepayment review has merit, identity methods of resolution, engage any internal personnel needed for resolution.
• Provide quarterly compliance trainings regarding new issues or to address deficiencies identified.
• Assist with training and trouble-shooting for payment deficiencies.

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Requirements

Knowledge, Skills, & Abilities

• Excellent organizational skills
• Excellent written and oral communication skills
• Excellent analytical skills

Education & Experience Requirements

• Undergraduate degree in related field preferred
• Extensive knowledge of ICD10-CM and CPT coding principles and guidelines
• Extensive knowledge of federal regulations and policies pertaining to physician documentation, coding, and billing
• 4+ years coding experience
• 3+ years auditing experience
• 1-2 years supervisory experience
• Ability to exercise judgment and propose courses of action where precedent may not exist.
• Experience in medical billing and compliance in healthcare preferred.

Supervisory Responsibilities

Manages payer appeals specialist.