Coding, Billing & Reimbursement Compliance Officer

Apex Medical Center

Job Description: With limited supervision from the Chief Compliance Officer identifies, investigates and resolves all compliance issues relating to coding, billing, documentation and reimbursement activities. As appropriate, acts as the team leader for special compliance investigations in coding, billing and reimbursement including formal and informal audits, cost reporting, charge master, computer billing system, and various compliance related computer systems.


Typical Activities:

Reviews and studies all information published by HCFA and the OIG via the Federal Register, fraud alerts, OIG advisory opinions, and other publications relative to coding, billing and reimbursement compliance.

Reviews and studies all information from third party payers relative to claims filing, coding, and the adjudication process.

Subscribes to and reviews various publications both in written form and through the Internet relative to coding, billing and reimbursement compliance.

Reviews, assesses, studies, analyzes the overall coding, billing, documentation and reimbursement system for potential compliance problems and non-compliant activities.

Uses a systematic approach for the identification and resolution of complex compliance problems.

Works with health information management, patient accounts, information system and other medical center personnel to solve and implement solutions to maintain a proper compliance stance.

Works with the Chief Compliance Office and medical center legal counsel relative to difficult coding, billing and reimbursement compliance issues.

Works with charge master and cost report personnel relative to maintaining proper compliance with various rules and regulations.

Works with contract management personnel in the review of contracts and other reimbursement or payment arrangements.

Works with the Chief Compliance Officer in the development and ongoing activities involved in the baseline and periodic compliance audits.

Conducts informal audits on various aspects of the coding, billing, documentation and reimbursement system.

Designs and conducts formal audits of specific aspects of the overall coding, billing and reimbursement system.

Develops and directs technical teams in the investigation and resolution of complex compliance problems.

Works with medical center legal counsel in developing systems to meet any requirements in a compliance settlement agreement including training, reporting and computer system utilization.

Provides training sessions for both general and specific problem resolution in the coding, billing and reimbursement area.

Writes and assists others in writing various types of policies and procedures in order to maintain proper compliance.

Attends workshops and seminars to maintain a high level of knowledge and capabilities.

Recommends and coordinates the use of consultants for specialized activities relative to the coding, billing a reimbursement compliance area.

Coordinates and facilitates problem resolution sessions where multiple departments and/or service areas are involved.

Monitors overall compliance in the coding, billing, documentation and reimbursement area.

Works with upper management and the Chief Compliance Officer relative to presentations and briefing of the Board of Directors

Works with upper management in planning and organization of new service areas and acquisitions of service providers.

Works with the financial department to optimize reimbursement while maintaining proper compliance status.

Addresses special projects as assigned.

Knowledge, Skills, Abilities and Personal Characteristics:

Extensive knowledge of various compliance rules and regulations in the coding, billing and reimbursement areas.

Extensive knowledge of the various sources and resources for information at the federal, state and local level in the compliance area.

Extensive knowledge of the various payment systems including DRGs, APCs/APGs, RBRVS, RUGs-III and various managed care and capitated arrangements.

Extensive knowledge of the various coding systems used by hospitals and physicians including CPT, HCPCS, and ICD-9-CM.

Knowledge of the charge master, its use, design, revenue center codes, relationship to CPT/HCPCS coding and overall impact on the coding, billing and reimbursement process.

Knowledge of computer hardware and software its use, function and design relative to coding, billing and reimbursement.

Extensive knowledge of computer software for both prospective and retrospective review of coding, billing and reimbursement compliance.

Knowledge of statistics and the process for developing audit sample sizes and selection of cases for review.

Knowledge of the auditing process including various techniques relative to auditing and problem resolution.

Knowledge of team dynamics and the process of building consensus.

An overall understanding of financial management and reporting in health care.

An overall knowledge of the functions and activities of hospitals and medical clinics.

Ability to participate with upper management in a decision support mode through the development of appropriate management information.

Knowledge of the charge development process and the interrelationship of cost accounting, cost management and related functions.

Ability to effectively work with and coordinate the activities of outside consultants.

Ability to work with outside auditors relative to formal compliance auditing situations.

Ability and skill to influence personnel through a matrix organization as opposed to line management authority.

Ability to develop and lead teams toward stated objectives and goals.

Skill in using personal computers for financial analysis (spreadsheets), data base development and report generation.

Knowledge and skill in using personal computers for electronic mail communications and Internet access along with internal intranet utilization.

Skill in performing research with bibliographic data bases and Internet access to associated information resources.

Skill in networking both directly through colleagues and professional organizations along with the ability to utilize networking capabilities through Internet news groups and list servers.

Interpersonal communication skills for training and working with personnel in sometimes tense situations.


Educational Background and Certifications:

Masters Degree in Healthcare Administration or Business Administration is highly desirable.

Appropriate certification in risk management and/or health care compliance highly desirable.

Five to ten years progressive experience in financial management, information systems and/or health information management is required.

All applicable certifications provided by the ACHE, HFMA, AHIMA, AGPAM and/or associated organizations are desirable.


Reports To:

Chief Compliance Officer.


Subordinate Personnel:

Subordinate staff is provided as needed and/or may be provided on a special project basis.


Notes: This is a highly responsible position that requires both quantitative and interpersonal skills.