Manager, Compliance (Medical Billing)
Requisition # 201993
Title: Manager, Compliance
Department: Corporate Compliance
Location: UMass Memorial Medical Center – 1 Biotech Park, Worcester, MA.
Manages a team responsible for conducting UMass Memorial Health Care (UMMHC) compliance auditing and monitoring (inpatient and outpatient coding and billing audits) which includes, but is not limited to, audit planning, conducting the audit, maintaining documentation, implementing corrective actions, drafting reports, preparing reports, and presenting findings as related to internal billing compliance audits. This position also manages responses to external government audits or commercial audits from payer physician and/or fraud units. Provides compliance education and communications to caregivers and/or management.
- Manages proactive compliance audits of inpatient and outpatient documentation, coding and billing in accordance with the Compliance Work Plan and other identified risks to assess compliance with Medicare, Medicaid and other third-party coding and billing requirements.
- Prepares and presents written audit plans, and reports of audit findings and recommended corrective actions.
- Oversees the tracking of management responses to audits and the completion of corrective actions.
- Identifies charge corrections and refunds resulting from audits.
- Develops, manages and updates audit policies, procedures, tools, and templates in collaboration with leadership.
- Manages the audit documentation electronic record-keeping system.
- Coordinates responses to government or other external audit or investigative requests or consultant audits to ensure responses are submitted in a timely manner, with appropriate tracking and reporting.
- Provides compliance training in Code of Ethics and Business Conduct, coding, billing, or other compliance related topics as needed.
- Researches and remains current on inpatient and outpatient documentation, coding and billing rules.
- Works with other functions, as appropriate, to develop materials based on audit findings for use in education and communication to clinicians and/or providers as well as administrators, coders, and billing staff.
- Assists the Chief Compliance Officer- Revenue Cycle in the development of an annual audit plan and in the prioritization of audits on an ongoing basis.
- Researches topics, assimilates information, and communicates effectively in person and in writing.
- Bachelor’s degree.
- American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC) certification, (Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), or Certified Professional Coder/Certified Outpatient Coder (CPC/COC) to demonstrate coding expertise.
- Minimum five (5) years of billing, coding or documentation audit experience in a health care provider or payer organization, including a minimum of one (1) year of supervisory/management experience.
- Working knowledge of auditing techniques and auditing standards.
- Working knowledge of various payment methods for inpatient and outpatient services, health care regulations, medical necessity requirements, clinical terminology and coding guidelines such as ICD-10-CM and CPT-4.
- Strong PC literacy (Microsoft Word, Excel, SharePoint, PowerPoint and EPIC).
- Strong verbal, written and communication skills.
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