Reporting to the Director of Billing Compliance, the Billing Compliance Reviewer plans and executes risk-based audits, analyzes documentation and coding for medical necessity and regulatory adherence, and recommends corrective actions to mitigate compliance risk. The role evaluates the accuracy and integrity of hospital and professional billing practices to ensure compliance with federal and state regulations, payer requirements, national coding guidelines, and internal policies. The Billing Compliance Reviewer is responsible for developing clear findings, collaborating with clinical and administrative stakeholders to resolve issues, and supporting continuous improvement in charge capture, documentation, and coding processes. This role works collaboratively with Coding, HIS, Billing and other internal and external teams to evaluate complex billing issues and initiate appropriate internal and external audit responses.

• Manage auditing software functions by setting criteria for routine audits including tracking tools and report generation.
• Audit and analyze the documentation accuracy, medical necessity, and billing code selection in alignment with CMS, OIG, and other applicable professional and technical services regulations and guidelines.
• Provide targeted education and feedback to physicians, APPs, coders, and staff on documentation, coding, and billing requirements; contributes to policy/procedure updates aligned with regulatory and payer guidance.Effectively monitor and create reports with detailed feedback for providers as well as clinical and administrative leadership.
• Partner with clinical providers, coding/HIM, revenue integrity, pharmacy, nursing, research billing, and practice operations to remediate findings, implement internal controls, and monitor corrective actions; track effectiveness of remediation through defined metrics. Assist in the development of new billing compliance guidelines, procedures and training programs designed to enhance the effectiveness of the compliance program, including the participation in personal development activities.
• Special projects as assigned.

Minimum Job Qualifications:

Minimum Education:
High school diploma required. Bachelor's degree preferred.

Minimum Experience:
5 years of experience in a healthcare coding environment. Knowledge of CMS (Medicare and Medicaid) and commercial payers billing and documentation guidelines required. Prior experience with Epic preferred.

License/Certification/Registration Required:

Certified Coder required (CPC, CCS, RHIT, or RHIA).

Supervisory Responsibilities:

None

Patient Contact:

No

The hiring range is based on market pay structures, with individual salaries determined by factors such as business needs, market conditions, internal equity, and based on the candidate's relevant experience, skills and qualifications.

For union positions, the pay range is determined by the Collective Bargaining Agreement (CBA).

$93,800.00 - $106,000.00