Sr Billing Compliance Reviewer

Location US-MA-Brookline
Job Posted Date 1 month ago(1/16/2018 12:22 PM)
Job ID
Hidden (8713)
full time


Reporting to the Director of Billing Compliance, the Sr. Billing Compliance Reviewer will be responsible for the identification and performance of Billing Compliance activities. The Sr. Reviewer will assist in the development and execution of the annual Billing Compliance work plan. S(he) 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.   S(he) will also manage all external hospital billing compliance audit activity including timely response, process improvement and corrective action plans from implementation through completion. Metrics will be developed and reported monthly. The Reviewer will be expected to pursue successful completion of multiple tasks collaborating effectively with many departments across the institute. The ideal candidate is organized, independent, ethical and motivated.


  • Assist in creation and manage execution of annual Billing Compliance work plan for services including ad hoc audits as they arise. Audits to be performed each year are identified based on the then-current Office of the Inspector General Work plan and compliance risk analyses
  • Process paybacks including report generation, check requests, cover letters and other supporting documentation as required
  • 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 MDAudit software functions by setting criteria for quarterly, semi-annual, annual and biennial physician audits including tracking tools and reports generation.  Interface with MDAudit support staff to troubleshoot issues and implement software program changes
  • Utilize Cobius Audit Tracking Tool reports, manage external hospital audits, including 60 day response cycle for governmental audits and conduct education as necessary or needed
  • Coordinate, assist and/or conduct billing compliance investigations as required, which may include audits designed to review the adequacy of medical record documentation to support claims as well as inquires into suspected or reported deviation from billing compliance program requirements
  • Design and complete monthly reporting metrics
  • Assist in the development of new billing compliance guidelines, procedures, and training programs designed to enhance the effectiveness of billing compliance program, including the participation of personal development activities
  • Attend meetings as requested. Serve as a liaison and collaborate with business partners (revenue cycle, nursing, clinical operations, HIS, ancillary departments, etc.). The Reviewer is expected to actively participate in various meetings, including Charge Capture, Epic Clinical Users Workgroup, Partners Coding & Billing Compliance Committee, as well as other continuous quality improvement processes and workgroups as needed
  • Compile weekly team member summaries and track progress and pass rates for scheduled provider audits
  • Perform Special projects as assigned
  • Work with the educator to enhance existing training programs, documentation tools and tips sheets


  • Coding certification required (AAPC, AHIMA)
  • Minimum 5 years’ experience in a healthcare coding or billing environment including prior auditing experience
  • Demonstrated knowledge of CMS (Medicare and Medicaid) Guidelines, commercial payers’ billing and documentation guidelines, current coding resources, including CPT4, ICD-10-CM/PCS, HCPCS


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