Senior Billing Compliance Reviewer

Location: Must live and work from one of the New England states (ME, NH, VT, MA, RI, CT).

Reporting to the Director of Billing Compliance, the Senior Billing Compliance Reviewer ensures the integrity, accuracy, and regulatory compliance of Dana‑Farber Cancer Institute’s hospital and professional billing through data‑driven audits and targeted monitoring. This role conducts complex, risk‑based audits across coding, charge capture, and documentation to assess adherence to government, payer, and institutional billing guidelines as well as national coding guidelines.

The Senior Reviewer assists in the development and execution of the annual Billing Compliance work plan, monitors federal and state regulatory requirements, and reports metrics quarterly. They collaborate effectively with many departments to accomplish tasks across the Institute and its affiliates. The ideal candidate is organized, independent, ethical, and motivated.

Located in Boston and the surrounding communities, Dana‑Farber Cancer Institute is a leader in life‑changing breakthroughs in cancer research and patient care. We strive to create an inclusive, diverse, and equitable environment, providing compassionate and comprehensive care to patients of all backgrounds and design programs to promote public health, especially among high‑risk and underserved populations.

• Assist in creation and manage execution of annual Billing Compliance work plan for services including focused audits as they arise across professional and hospital services, including coding accuracy, documentation sufficiency, charge capture, modifiers, and claim edits. Audits to be performed are identified based on the then‑current Office of the Inspector General work plan and internal and external compliance risk analysis.
• Perform targeted pre‑bill and post‑bill reviews (e.g., E/M, infusion/chemotherapy, radiation therapy, imaging, ancillary services) aligned to CMS regulations, payer policies, LCD/NCD requirements, and NCCI/MUE edits.
• Analyze audit results to identify trends, root causes, and systemic issues; develop clear, concise reports with recommendations and collaborate with stakeholders to design corrective action plans and preventive controls.
• Provide education and coaching to physicians, Advanced Practice Providers (APPs), nursing/infusion teams, coding, and revenue cycle staff on documentation, coding, and billing requirements; update materials to reflect changing regulations and payer guidance.
• Monitor implementation of remediation activities, validate effectiveness through follow‑up audits, and maintain auditable documentation of findings, action plans, and outcomes.
• Process paybacks including report generation, check requests, cover letters and supporting documentation as required for delivery to Chief Compliance Officer for final submission to payer.
• Support enterprise risk assessments, strategic growth, and annual audit planning by assessing emerging regulatory changes (e.g., OIG Work Plan, CMS transmittals, CPT/ICD updates) and internal operational risks, recommending audit priorities and monitoring strategies.
• 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 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 inquiries into suspected or reported deviation from billing compliance program requirements.
• Design and complete quarterly reporting metrics.
• Assist in the development of…