Lead compliance oversight and independent review across Koya Medical's DME order-to-payment lifecycle, from intake and documentation through authorization, delivery, billing, appeals and patient financial responsibility. This hands-on manager independently designs audits, analyzes data, investigates revenue-cycle patient complaints and coordinates external payer audits. The role develops practical controls, validates corrective actions and provides clear reporting to Compliance leadership.
Essential responsibilities
• Independently develop and execute risk-based audits. Define objectives, criteria, populations, sampling methods, testing procedures and evidence standards; maintain reproducible workpapers and supported conclusions.
• Review intake, eligibility and benefits verification, coordination of benefits, orders, medical necessity documentation, prior authorization, proof of delivery and payer requirements. Assess handoffs and controls throughout the order lifecycle.
• Audit Medicare and commercial billing, payer contract adherence, out-of-network practices, capped rental progression, continued eligibility and use documentation, returns, interruptions, repairs, replacements and modifiers. Review denials, appeals, timely filing and same-or-similar issues.
• Evaluate patient responsibility estimates and communications, QMB protections, balances, collections, Compassionate Care and other financial hardship activity, write-offs, refunds and potential overpayments. Escalate findings requiring repayment assessment or legal review.
• Lead compliance investigations of Medicare and commercial patient complaints involving coverage representations, documentation, authorization, delivery, billing, appeals, financial assistance, refunds and supplier practices. Gather evidence, document findings, coordinate resolution and identify recurring risks.
• Lead coordination and compliance review of Medicare and commercial payer audits. Track requests and deadlines, assess documentation quality and response completeness, coordinate approved submissions, analyze findings and support appeals and corrective actions.
• Analyze claims, order and patient-account data using strong Excel skills. Reconcile datasets, identify exceptions, maintain reliable dashboards and explain trends and exposure estimates with appropriate limitations.
• Conduct root-cause analysis with operational owners; document corrective actions, responsibilities and deadlines, and independently validate effectiveness. Escalate overdue actions, repeat findings and significant patient or reimbursement risks.
• Prepare concise written findings and management-ready presentations. Recommend policy updates and targeted training. Conduct selected other compliance reviews under the Director's approved work plan.
Authority and working relationships
The Manager reports to the Senior Director, who retains responsibility for compliance governance and oversight of significant investigations. The Manager leads assigned audit work, coordinates payer audits and conducts substantive revenue-cycle patient complaint reviews. External communications follow delegated approval authority.
The Manager independently accesses data from internal systems, requests records and explanations needed for approved reviews, and promptly escalates suspected improper billing, discrepancies or other compliance concerns. Operational leaders retain responsibility for order processing, claim submission, collections, routine appeals, service resolution and corrective-action execution; the Manager evaluates compliance and validates corrective-action effectiveness. Finance retains ownership of accounting and internal control over financial reporting (ICFR). This role supports the Compliance function and does not replace independent Internal Audit assurance.
Required qualifications
• Bachelor's degree in healthcare administration, accounting, finance, business or a related field, or equivalent relevant education and experience.
• At least five years in healthcare compliance, reimbursement audit or revenue integrity, including direct Medicare DMEPOS experience and at least two years independently leading audits, compliance reviews, or cross-functional improvement projects.
• Practical knowledge of the DME order-to-payment lifecycle, capped rentals, documentation, authorizations, payer requirements, patient financial protections and refund and overpayment workflows.
• Demonstrated ability to design and execute an audit from inception through findings, root-cause analysis and corrective-action validation. Experience supporting external payer audits and resolving complex compliance issues.
• Strong Excel skills, including data reconciliation, lookup functions, pivot tables and exception analysis. Ability to produce clear findings reports and concise PowerPoint presentations for leadership.
• Sound investigative judgment, discretion, effective cross-functional communication and the ability to coach colleagues while personally performing detailed work.
Preferred qualifications
• National DME supplier experience; Medicare patient complaint investigations; compliance-program development or public-company readiness.
• CHC, CPMA, or another relevant credential.
• SQL, Power BI, Salesforce, compliance case-management tools, and healthcare billing-system experience.
• Experience supporting payer audits, compliance-program development or public-company readiness.
First year priorities and success measures
• First 90 days: map order-to-payment risks, assess high-risk billing workflows, establish baseline error measures and a documented audit plan, and complete initial priority reviews.
• By six months: implement consistent workpapers, recurring dashboards, complaint and payer-audit tracking, and corrective-action validation.
• By year end: demonstrate sustained improvement in targeted controls, reduced repeat findings and reliable evidence for leadership oversight.
• Measure audit quality and completion, data reliability, complaint and audit-response timeliness, appropriate escalation and remediation effectiveness.
Work requirements
Work involves confidential records, computer-based analysis, meetings and staff training. Occasional travel may be required for business needs. Koya Medical provides equal employment opportunity and reasonable accommodation in accordance with applicable law. This description outlines the primary responsibilities of the position; related duties may be assigned as business needs evolve.
Note
This job description in no way states or implies that these are the only duties to be performed by the employee(s) incumbent in this position. Employees will be required to follow any other job-related instructions and to perform any other job-related duties requested by any Koya manager authorized to provide instruction or assign work. Duties, responsibilities, and activities may change at any time with or without notice.
All duties and responsibilities are essential functions and requirements and are subject to possible modification to reasonably accommodate individuals with disabilities. To perform this job successfully, the incumbents will possess the skills, aptitudes, and abilities to perform each duty proficiently. Some requirements
may exclude individuals who pose a direct threat or significant risk to the health or safety of themselves or others. The requirements listed in this document are the minimum levels of knowledge, skills, or abilities. This document does not create an employment contract, implied or otherwise, other than an "at will" relationship.
#LI-REMOTE
The pay range for this role is:
120,000 - 135,000 USD per year (Remote (United States))
