Compliance Specialist, Hospital Billing

Legal & Compliance Worcester, Massachusetts


Position at UMass Memorial Health

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At UMass Memorial Health Care, Everyone is a Caregiver regardless of title. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health care system of Central and Western Massachusetts, and a place where we can help you build the career you deserve. We are more than 14,000 employees, working together as one health care system. And everyone, in their own unique way, plays an important part, everyday.

Requisition #:  230016
Title:  Compliance Specialist, Hospital Billing
Department:  Corporate Compliance
Location: UMass Memorial Medical Center
Posting Date: 8/2/22
Shift:  Days
Status: Exempt
Hours:  M-F, 8AM-5PM
Shift Length: 8
Position Summary:
Reporting to the UMMHC Hospital Compliance Audit Manager, the Hospital Billing Compliance Specialist performs a wide range of duties involving the review of UMMHC hospitals’ inpatient and outpatient documentation, coding and billing practices.  The Compliance Specialist is responsible for planning and performing audits, creating and maintaining appropriate work papers to support audit findings, and preparing reports of audit work including findings, conclusions and recommendations.  Presents audit findings / reports and provides department or individual education as needed in addition to monitoring and re-auditing if required.
The duties and responsibilities stated are a general summary and not all inclusive.
Major Responsibilities: 

  • Plans and performs proactive compliance audits of UMMHC hospital inpatient and outpatient documentation, coding and billing in accordance with the Compliance Work Plan and other identified risks in order to assess compliance with a primary focus on Medicare and Medicaid coding and billing requirements.
  • Demonstrates knowledge of the various payment methods for inpatient and outpatient hospital services.
  • Assists as requested with responses to government or other external audit or investigative requests.
  • Provides input to the development of the Compliance Audit Work Plan and prioritization of audits.
  • Supports all entities in relation to hospital billing compliance questions and compliance audit support
  • Develops specific audit plans to include the objective, regulatory billing requirement(s), scope, and methodology prior to commencing the audit.
  • Collaborates with Compliance Data Analyst and / or other IT personnel to obtain claim universe for audits.
Position Qualifications:
  • Bachelor's degree.
  • AHIMA or AAPC certification (RHIA, RHIT, CCS, or CPC/COC) to demonstrate coding expertise.
  • Three (3) years of relevant experience, or a minimum five years of billing, coding or documentation audit experience in a health care provider or payer organization
  • Working knowledge of auditing techniques and auditing standards.
  • Working knowledge of various payment methods for inpatient and outpatient hospital services, health care regulations, medical necessity requirements, clinical terminology and coding guidelines for ICD-10-CM/PCS, CPT-4, HCPCS.
  • Experienced in researching Federal and State Coding and reimbursement guidelines and regulations.
  • Strong PC literacy (Microsoft Word, Excel, SharePoint, and PowerPoint).
  • A minimum of one of the following:
  • Appropriate AHIMA or AAPC certification (RHIA, RHIT or CCS) to demonstrate coding expertise.
  • Nursing or other clinical degree.
  • Experience within Case Management, Utilization Management or Quality. 
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.

Standards of Respect: