Reporting to the Director of Billing Compliance, the Senior Billing Compliance Reviewer will be responsible for the identification and performance of Billing Compliance inpatient and ambulatory activities. The Senior Reviewer will provide oversight related to reviewing the accuracy and appropriateness of ICD-10-PCS procedure coding and assessing DRG assignment. The Senior Reviewer will assist in the development and execution of the annual Billing Compliance work plan. They will monitor federal and state regulatory requirements and industry developments and work to determine applicability and risk to both technical and operational aspects of the organization. Metrics will be developed and reported quarterly. The Senior Reviewer will be expected to pursue successful completion of multiple tasks collaborating effectively with many departments across the institute, Mass General Brigham Healthcare, Boston Children's Hospital and Beth Israel Deaconess Medical Center.

• Conduct and oversee the evaluation of ICD-10-PCS procedure coding to ensure accuracy and appropriateness, including assessment of DRG assignment
• Provide oversight for the review of the accuracy and appropriateness of ICD-10-CM diagnosis coding
• Assist in the creation and manage the execution of annual Billing Compliance work plan for services including focused audits as they arise. Identifies which audits to be performed each year based on the then-current Office of the Inspector General work plan and internal and external compliance risk analysis
• Process paybacks including report generation, check requests, cover letters and supporting documentation as required for delivery to Chief Compliance Officer for final submission to payers
• Review government and commercial payer policy updates (i.e., MCR NCD/LCD), regulatory, legal and industry developments for their applicability to the operation, determine risks and participate in the dissemination of relevant information
• Manage audit software functions by setting criteria for routine and focused professional and technical audits including tracking tools and reports generation. Interface with audit software Help Desk and other staff to troubleshoot issues and implement software program changes. Utilize audit software reports, manage external government hospital audits, including 60-day response cycle for government audits and conduct education as necessary
• Coordinate, assist with, and/or conduct billing compliance investigations and audits, including medical record documentation reviews to support claims and inquiries into suspected or reported noncompliance with billing program requirements
• Assist in the development of new billing compliance guidelines, procedures and training programs designed to enhance the effectiveness of billing compliance program, including participation of personal development activities
• Attend and actively participate in various meetings which may include CPT-Epic, New Services, Regional Campuses, Inpatient Billing, ADCC and AAMC as well as other continuous quality improvement processes and workgroups as needed
• Serve as a liaison and collaborate with business partners (revenue cycle, nursing, clinical operations, HIS, ancillary departments, etc.)
• Work to enhance existing training programs, documentation tools and tip sheets
• Special projects as assigned

Knowledge, Skills and Abilities:

• Knowledge of CMS (Medicare and Medicaid) and commercial payers billing and documentation guidelines, current coding resources, including CPT4, ICD-10-CM/PCS, HCPCS required.
• Strong interpersonal skills, including ability to establish and maintain effective relationships with providers, leadership, senior administration, colleagues, and billing compliance staff
• Excellent written and verbal communications, facilitation, and presentation skills used to share audit findings, risk areas and billing compliance issues identified
• Ability to work independently with limited supervision and willingness to be flexible depending on department needs
• Ability to balance and manage multiple priorities and flexibility to reprioritize tasks when needed
• Knowledge of various audit software, Epic and/or other comparable software and database tools
• Knowledge of hospital operations, reimbursement, and applicable regulatory requirements
• Ability to present findings and discuss issues with providers and other staff confidentially and effectively
• Strong attention to detail and highly organized
• Strong team player with ability to work well independently and as a group
• Ability to work under pressure, multitask and meet deadlines
• Technical capability to utilize multiple information systems and Microsoft applications

Minimum Job Qualifications:

• High School Diploma Required. Bachelor's degree preferred.
• 5 years of experience in healthcare coding including at least 2 years of inpatient/DRG experience.
• 1 year of prior auditing experience
• Epic hospital billing (HB), professional billing (PB) modules, 3M or other encoder preferred
• Cancer center experience preferred

License/Certification/Registration Required:

• Certified Coder required (CIC, CPC, CCS, RHIT, or RHIA).
• Health Care Compliance Association (HCCA) Certification in healthcare compliance (e.g., CHC) preferred

Supervisory Responsibilities:

None

Patient Contact:

None

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).

$116,700.00 - $132,000.00