Billing Compliance Manager

Description

Job Summary :

The Billing Compliance Manager provides oversight of coding operations with a focus on behavioral health and outpatient facility services.  This role ensures coding accuracy, documentation integrity, and compliance with federal, state, and payor regulations through internal audits, payer reviews, and accreditation-related activities. This position provides feedback, education, and training on the results of auditing. The individual is also responsible for carrying out the requirements and elements of an effective compliance program and enforcing HIPAA Privacy requirements, identifying risks and trends, developing effective internal controls, and providing education and feedback to staff and physicians. By maintaining rigorous compliance standards, this position supports accurate reimbursement, minimizes organizational risk, and upholds the quality and integrity of all coding and billing functions.

Essential Functions :

• Conduct regular audits of medical coding, billing, and documentation for accuracy and compliance with ICD-10, CPT, HCPCS, CMS, and payer-specific guidelines.
• Audit pre-bill encounters, identifying discrepancies, coding errors, and compliance risks.
• Ensure adherence to all applicable regulations, including HIPAA Privacy and Security requirements, and support ongoing compliance program initiatives.
• Conduct remote and on-site chart audits, including clinical observations, HIPAA compliance checks, education / supervision, and corrective action planning.
• Document audit findings clearly and concisely, communicating results through written reports, feedback calls, and structured presentations to leadership.
• Prepare audit conclusion reports that summarize findings, identify trends, and recommend corrective actions and process improvements.
• Collaborate with operational leaders to implement and monitor corrective action plans.
• Provide timely education, feedback, and coaching to providers, coders, and revenue cycle staff on audit results and coding requirements.
• Support performance improvement by meeting directly with physicians / clinicians or equipping practice managers and leadership with guidance for discussions.
• Develop and present compliance training programs, including updates on regulatory changes, coding guidelines, and payer requirements.
• Maintain current knowledge of coding regulations, accreditation standards (e.g., CARF), and industry best practices to ensure organizational alignment.
• Assist in carrying out the functions of the Compliance Program as directed by the SVP of Compliance and Risk and / or the Executive Leadership Team.
• Gather and analyze compliance data to identify risks, trends, and areas requiring further monitoring or training.
• Provide support through in-person meetings, virtual sessions, email, or phone for compliance-related issues.
• Prepare reports and updates for compliance leadership, executive teams, and regulatory purposes as requested.
• Assist in planning and executing audit projects from initiation through completion, including scheduling, data gathering, and follow-up tracking.
• Maintain compliance with all organizational policies and procedures while supporting operational efficiency and integrity.
• Provide administrative support as needed, including scheduling meetings, preparing documentation, and maintaining calendars.

Supervisory Responsibilities :

(Scope of the person's authority, including a list of jobs that report to this job)

Essential Qualifications :

(To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the competencies (minimum knowledge, skill, and ability) required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions)

Education / Licensure / Certification :   Bachelor’s degree in health information management or related field and Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent coding certification required .  Certified Professional Medical Auditor (CPMA) or similar auditing credential preferred

Required Knowledge :                 Must have knowledge of Methadone Maintenance Treatment.  Must be detail oriented.  The position requires strong clerical skills to ensure their organizational and recording responsibilities.  Possess a broad knowledge of revenue cycle, Common Procedure Terminology Codes, ICD-10 and the associated experience to understand the importance of the codified data presented to a health plan on a claim form.  Must also have good understanding and / or undergo training for random sample audit procedures.  Deep understanding of compliance documentation and billing for healthcare providers, as well as applicable Medicaid and other Third-Party requirements and other legal regulations. Knowledge of computer and internet applications, data management, and an understanding of reporting requirements. Proficiency in Microsoft and Google products.

Experience Required :      Minimum of 5 years experience in coding and billing for substance abuse treatment And; Minimum of 2-year auditing experience in the healthcare industry. Demonstrated experience utilizing electronic spreadsheets such as Google Sheet or Excel. Well-developed team skills, unquestioned integrity, and the experience, confidence, and presence to effectively handle interpersonal relationships and sensitive compliance issues.

Skill and Ability :      Ability to work with both technical and administrative personnel. Strong organizational skills with a keen ability to prioritize and multitask. Ability to adhere to and meet deadlines. Experience in handling sensitive and confidential information. Excellent communicator (oral and written) including the desire to ask questions and learn from co-workers. Strong administrative and data management skills. Ability to raise issues proactively and in a timely manner. Excellent customer service skills. Working knowledge of regulations for all states and all federal and laws. Strong administrative and data management skills.

Physical Demands / Work Environment :

(The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.)

Finger Dexterity :      Use primarily for writing, operating calculators, telephone, keyboard, and other office equipment.

Talking :      To convey detailed or important instructions to employees, patients, and applicants

Hearing :      Able to hear normal conversations and receive ordinary information.

Vision :      Average, ordinary, visual acuity necessary to prepare and inspect documents. Clear vision at 20 inches or less and distant vision at 20 feet or more

Physical Strength :      Sedentary work; sitting much of the time. Ability to lift up to 10 pounds. Movement such as standing, walking, and occasional bending or reaching is required. Exerts up to 10 pounds of force occasionally.

Working Conditions :

(The working conditions described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.)

Core Competencies

Job or State Requirements

Bachelor’s degree in health information management or related field and Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent coding certification required. Certified Professional Medical Auditor (CPMA) or similar auditing credential preferred. Must have knowledge of Methadone Maintenance Treatment.