Senior Billing and Reimbursement Compliance Manager - The Woodlands, Texas


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Dana Schneider
Recruiting Manager
Office: 281-203-6369 Cell: 832-247-0416 Fax: 281-681-2509

Robert Half Finance & Accounting | 10001 Woodloch Forest Drive | Suite 550 | The Woodlands | TX 77380 USA |

Senior Billing and Reimbursement Compliance Manager

About Us:
Emerus is a nationally recognized, innovative leader in the delivery of inpatient, surgical, and diagnostic medical health care. Specializing in the identification, development and management of improved-access community medical facilities, Emerus provides cost effective, scalable growth opportunities to large-scale, national health care systems throughout the United States.

By providing operationally efficient facilities and focused alignment with current health care trends, Emerus’ community-based hospitals prioritize limited inpatient stays, efficient emergency rooms and cost effective pricing in a smaller campus setting. Based in The Woodlands, Texas, Emerus has more than 1,400 employees, with expert concentrations in over 20 different fields throughout the medical industry.
Position Overview:
In this exciting position you will:
• Report directly to the Corporate Compliance Officer
• Further Develop and Manage the Coding & Reimbursement Compliance Program
• Audit & Monitor (Billing, Coding & Revenue Cycle) particular focus areas of the Finance Department
• Educate & Train company personnel regarding standard regulations & policies around Billing & Coding
• Report findings, training and recommendations

The purpose of this position is to oversee the daily operations of the Billing & Reimbursement Compliance auditing program and to ensure that the organization is in compliance with federal, state, and company guidelines. This position is also responsible for conducting audits of medical record documentation billed to third party payers. The audits will determine whether billed services provided to patients are consistent with medical record documentation and in accordance with the appropriate third party billing regulations and/or standards. This process entails auditing, research, special project, and refunding to governmental and commercial carriers upon the completion of investigations.

Essential Job Functions:
• Conducts prospective and retrospective inpatient and outpatient documentation audits to confirm compliance with documentation and billing rules and regulations set forth by the Centers for Medicare and Medicaid Services (CMS), Medicare Fiscal Intermediary, state regulations and company policies.
• Conducts quality assurance audits according to a random percentage of cases selected for each facility. Confirm cases with possible conflicts according to Compliance program guidelines.
• Maintains a thorough understanding of CPT, ICD-9-CM (ICD-10) and HCPCS coding principles, governmental regulations and third party guidelines regarding documentation and/or billing compliance.
• Act as a resource for Compliance staff and other staff according to the training schedule/modules assigned. This process includes specialized case assignments, documentation reviews, reviewing company policy and documentation guidelines.
• Develops and maintains a close working relationship with the Coding, Billing and Reimbursement staff to assure that documentation issues, pattern and/or trends are identified and addressed by prospective compliance education in a timely manner.
• Prepare and maintain audit work papers and audit reports; prepare recommendations for improvement and communicate compliance audit findings and recommendations to department/functional management for management's development of corrective action plans.
• Track corrective action plans for completion and conduct follow-up with management as appropriate to foster successful completion and achieve compliance.
• Develop periodic report of auditing and monitoring activities, findings, risk levels, recommendations, status or corrective action plans, and outcomes.
• Collaborate with appropriate personnel for the development, review and implementation of compliance-related policies, procedures, educational initiatives or workflows relating to clinical, billing, coding or other business activities pertinent to the Compliance Program.
• Conduct and/or assist with investigations of reported or identified allegation of violations.
• Assist in the drafting of self-reporting disclosure letters to government agencies or managed care payors.
• Create monthly refund reports for Billing Compliance to ensure inadequate payments received are refunded to the appropriate carriers. Assist in the completion of any special projects, documentation reviews, and investigation. Update the investigation case log and report any refundable cases on the monthly Refund Report.
• Remain current with new rules, regulations and revisions, as set forth by the Center for Medicare and Medicaid Services (CMS) and other entities regarding billing compliance. Develop training and education sessions for Billing Compliance staff. Utilize documentation examples while providing rules and regulations as they apply to Medicare, CCI edits, LCD’s and institutional guidelines.
Other Job Functions:
• Attend staff meetings or other company sponsored or mandated meetings as required
• Perform additional duties as assigned
Basic Qualifications:
• Bachelor’s Degree in Finance, Business, Nursing or related field or in lieu of a degree, 2 additional years direct experience as described below.
• 3 years of experience in legal, regulatory and/or compliance in a healthcare setting is required with direct experience in understanding and implementing government regulations. Licensed RN and/or coding certification (CPC or CCS) required; CPC-H preferred.
• One of the following is required: Strong working knowledge of compliance, auditing, and monitoring techniques.
o Certified Professional Coder (CPC or CPC-H) by the American Academy of Professional Coders.
o Certified Coding Specialist-Physician (CCS-P) by the American Health Information Management Association (AHIMA).
o Registered Health Information Administrator (RHIA)/ Registered Health Information Technician (RHIT) by AHIMA.
• Strong working knowledge of compliance, auditing, and monitoring techniques.
• Excellent analytical, organizational, written, verbal and presentation skills are required with the ability to communicate with individuals at all levels of the organization and externally.
• Ability to solve problems independently and in a timely manner.
• Strong understanding of medical terminology, ICD, CPT, and HCPCS coding and medical billing processes.
• Experience in billing & coding emergency and/or hospital inpatient services.
• Thorough knowledge of government regulations relating to medical records documentation and reimbursement including Medicaid, Medicare, HIPAA, Accrediting Agency, etc.
• Proficiency with Microsoft Office software applications
• Position requires fluency in English; written and oral communication