Summary:The Associate Director leads the resolution of complex compliance issues by conducting thorough analysis, research, documentation, and reporting, while collaborating with relevant stakeholders to ensure the Office of Institutional Compliance receives accurate and actionable information to support timely, well-informed decisions that advance organizational compliance objectives.
Responsibilities:INVESTIGATIONS/AUDITS:
- Partners with Compliance Attorneys and/or other management teams throughout the institution to research deficiencies, conduct investigations, and develop post-review memorandums, which include guidance and recommendations for issues related to HIPAA violations, conflicts of interest (COI), patient and employee hotline allegations, billing disputes and others compliance related concerns.
- Performs, or assists in the performance of, special reviews or investigations at the request of management.
- Serves as project lead for external reviews performed by regulatory agencies and non-regulatory agencies (such as consulting firms). Updates the investigation and audit tracking databases, as necessary.
- Works closely with Revenue Cycle Operations, Medical Records, and other departments to ensure that records requests and appeals are timely submitted for various auditing bodies such as Medicare, Medicaid, RACs, HRSA, MSP, ADR, CERT, SMRC, OIG (federal and state), etc. Develops various auditing workflows by payor, which identify the department(s) that is/are responsible for each step in the process.
COMPLIANCE LIAISON:
- Works in close collaboration with other Compliance staff and/or other management teams throughout the institution to ensure program-wide compliance efforts are in alignment with the Centers for Medicare & Medicaid Services (CMS), Texas Health and Human Services Commission (HHSC), Commercial Payors, and other Federal and State regulatory requirements.
- Serves as the institutional liaison with regulatory agencies, including but not limited to, the Medicare Administrative Contractor, the Center for Medicaid and Medicare Services, TXHHSC, Recovery Audit Contractors (RACs), Texas Medical Board (TMB) and other payors and regulatory bodies for requests for information, including triaging and overseeing outside regulatory agency reviews and audits and requests for information, and communicating with regulatory agencies in determining the direction, theory, scope and procedures to be used in compliance reviews.
- Provides reports to executive leadership regarding current and/or expected audit activity, trends, financial exposure, and remediation or corrective measures.
- Provides strategic recommendations for corrective and mitigation actions in response to regulatory or internal reviews, ensuring compliance processes and functions are strengthened and aligned with organizational and regulatory requirements.
GENERAL COMPLIANCE ACTIVITIES:
- Maintains comprehensive knowledge of evolving rules, regulations, and guidance issued by the State Legislature, CMS, TXHHSC, Medicare Administrative Contractors, and other regulatory or oversight entities to ensure organizational compliance functions remain current and effective.
- Leads or contributes to the development and delivery of training and educational programs for compliance staff, including monitoring audit contractor publications and websites, and actively participating in professional forums such as Novitas, Novitasphere, HMS Medicaid RAC, Cotiviti RAC, Performant, VA RAC, Federal and State OIG, and CMS Open Door Forums, to ensure the team is informed of emerging trends and regulatory changes.
- Serves as a subject-matter resource for complex compliance questions, supporting staff and leadership in interpreting regulatory requirements and applying them to organizational operations.
- Collaborates with internal departments to implement best practices and standard operating procedures that ensure consistent adherence to federal, state, and payer regulations.
MEETINGS/COMMITTEES:
- Chairs the Audit Request and Appeals meetings and the Compliance Oversight Committee (COC), establishing strategic agendas, guiding discussions to ensure regulatory and operational priorities are addressed, overseeing accurate documentation of minutes, and driving accountability through follow-up on action items and implementation of decisions.
- Supports the Executive Billing Compliance Committee by generating and analyzing audit reports, presenting key findings to executive leadership, and addressing follow-up inquiries as requested.
- Provides strategic updates on emerging audit trends, payer changes, and compliance developments to inform decision-making and support organizational risk management.
- Actively participates in and provides leadership support for committees such as the ABN Utilization Meeting, Medicare Secondary Payor (MSPQ) Task Force, and other ad hoc or emerging committees; organizes and prepares reports, meeting summaries, and actionable recommendations to support informed decision-making and drive organizational priorities.
- Participates in the 340B meeting by preparing agendas, coordinating minutes, and ensuring accurate documentation of discussions; serves as acting chair in the absence of the Deputy Chief Compliance Officer, guiding discussions and facilitating follow-up on action items.
- Coordinates follow-up tasks generated during committee meetings, ensuring cross-functional collaboration and timely completion of action items prior to subsequent meetings.
RESEARCH AND REPORTING:
- Evaluates relevant statutes, regulations, and guidance in response to concerns brought to the Office of Institutional Compliance, ensuring that organizational decisions and actions are informed by accurate interpretation of applicable rules and regulatory requirements.
- Prepares and delivers clear, concise, and strategic presentations on compliance matters, audit findings, and regulatory updates to executive leadership, committees, and cross-functional stakeholders, effectively translating complex information into actionable recommendations.
- Performs specialized research across a host of regulatory billing and compliance issues utilizing EPIC and software platforms to discern information contained in the medical record, charges for services, and payments.
- Composes letters to external agencies, such as HHSC-OIG and pharmaceutical companies, on behalf of UTMB, which contains detailed information related to patient care and/or billing practice issues and references applicable policies and statutes.
- Prepares quarterly reports for the Executive Billing Compliance Committee (EBCC) detailing trends, overpayments, underpayments, and items of statistical relevance related to governmental investigations and audit. Runs ad hoc reports as needed for focused reviews or to identify trends.
SOFTWARE/THIRD-PARTY VENDORS/INVOICING:
- Serves as Global Administrator for auditing tracking software, managing user access, overseeing system upgrades and implementation builds, and providing financial analysis and cost estimates related to software utilization to support strategic decision-making.
- Reviews and reconciles invoices for payment approval related to third-party billing for appeals submitted by third-party vendors on UTMB's behalf and provides estimates of expenses for budgeting purposes.
- Assists Finance with estimates related to large expenditures which may require establishing reserves.
- Leads special projects at the request of the Chief Compliance Officer or Deputy Chief Compliance Officer, as needed.
- Adheres to internal controls and reporting structure.
- Performs related duties as required.
Knowledge, Skills & Abilities:- Knowledge of hospital/physician billing, auditing, and reporting systems such as EPIC, Slicer Dicer and/or MD Audit.
- Attention to Detail - Precision in both writing and reporting.
- Communication Skills - Clear communicator with executive leadership, internal departments, and external stakeholders.
- Critical Thinking - Ability to evaluate diverse cases and effectively develop solutions.
- Proficient in Microsoft Office Suite (Word, PowerPoint, Excel).
Minimum Qualifications:- Bachelor's degree in a related field plus seven (7) years of experience in healthcare administration, with an emphasis on compliance related functions.
Preferred Qualifications: - Master's degree in a related field.
- Work experience in an academic medical center or hospital system.
- Certified Professional Coder-Hospital (CPC-H) by the American Academy of Professional Coders.
- Certified Professional Medical Auditor (CPMA) by the American Academy of Professional Coders.
- Certified Coding Specialist-Physician (CCS-P) by the American Health Information Management Association.
- Certified Coding Specialist (CCS) by the American Health Information Management Association.
- Certified in Healthcare Compliance (CHC) by Health Care Compliance Association.
- Certified Fraud Examiner (CFE) by the Association of Certified Fraud Examiners.
- EPIC Certification.
