General Description: Under general direction of the Billing Compliance Director, this position is responsible for the identification, review, investigation and resolution of billing and coding compliance issues and patient complaints. This position is also responsible for chart auditing, report composition and reporting that clearly outline key performance indicators and provide educational feedback to those providers/service areas who are not in compliance with regulated billing and coding practices.

The role of this position is to provide billing/coding compliance guidance/assistance to providers before, during or after account reviews are conducted or billing/coding compliance issues are identified in accordance with CMS billing guidelines.

Essential Responsibilities:

Responsibilities listed in this section are core to the position. Inability to perform these responsibilities with or without an accommodation may result in disqualification from the position.

Reviews will include but not limited to:

• Quality Assurance audits on proper CPT/HCPCS modifier utilization
• CMS regulatory updates and other notifications (i.e. Med Learn Matters Articles)
• OIG and physician billing compliance workplan items
• NCD/LCD (guidelines/articles)
• ABN compliance - Delivery, completion and appropriate modifiers applied in patient accounting system.
• Charge capture and validation (clinic and procedural)
• Reimbursement validation
• CMS Open Payments validations (physician reviews and attestations)
• Appropriate Use Criteria (AUC)
• Government requests/rebills - Tracking (Targeted & Probe Education - TPE, Comprehensive Error Rate Testing - CERT, Recovering Audit Contractors - RAC) and initiating reviews based on the government payer's responses.
• Clinical Research billing validation - Ensuring that claims submitted to Medicare have the appropriate modifiers appended.
• STARK - account identification and review when assigned by Legal
• Telehealth - Ensuring that documentation supports service and is in accordance with CMS telehealth guidelines.
• Patient account investigations (ID Theft, Complaints, Drug Diversion - Charge identification and request for reversal only)
• Cash Audits - Ensuring that cash receipts are properly accounted for and documented.
• Collaborating with external department members to seek the best practice/resolution based on CMS guidance.
• Collaboration with creation and monitoring action plans.
• Compiling reports to be presented at the Billing & Coding Compliance Committee
• Collaborating with the creation of educational and training tools

General Responsibilities:

• All other duties as assigned.

Minimum Requirements:

Education: High School Diploma or GED required.Associates or Bachelor's degree in HIM/HIT preferred.

Experience: 4 or more years of billing experience (professional and/or facility billing) required.

OR equivalent combination of education and experience.

Licensure/Certifications/Registrations Required: Certified Professional Coder certification required

Knowledge, Skills & Abilities:

• Ability to perform effective research and prepare documents utilizing Microsoft Excel a.
• Detail oriented.
• Excellent organizational skills.
• Good verbal and written communication skills.
• Ability to work independently and as part of a team.
• Ability to coordinate a varying workload and be flexible towards changing priorities.
• Ability to apply knowledge and make decisions quickly and accurately.
• Strong computer skills to include Microsoft Word and proficiency with Excel and Power Point.