Billing and Coding Compliance Specialist

Position Summary

The Billing and Coding Compliance Specialist supports the Compliance & Risk Department by mitigating billing and coding risk, developing and maintaining internal audit activities, and facilitating workforce billing and coding education.

• Conduct Internal Monitoring and Auditing
  • Support the Compliance & Risk Department's efforts to promote compliance with payor and regulatory guidelines and prevent fraud, waste, and abuse.
  • Develop internal billing, coding, and documentation audit plan(s) to ensure that workforce members abide by ethical billing and coding practices.
  • Perform routine and targeted audits of billing, coding, and documentation.
  • Recommend corrective action plans to remediate billing and coding risk.
• Data Analysis and Reporting
  • Develop key metrics related to billing and coding practices, audit activity, and claims data.
  • Generate, analyze, and distribute reports summarizing key metrics.
• Support and Promote Effective Lines of Communication
  • Monitor and manage billing and coding-related reports submitted to the compliance hotline.
  • Field workforce outreach related to billing and coding compliance.
• Investigate and Respond
  • Investigate and respond to billing and coding compliance-related inquiries.
  • Monitor external audit activity and support mitigation of high‑risk audits.
  • Develop corrective action plans and best practice recommendations related to billing and coding activity.
• Training and Education
  • Support educational initiatives on a regular and ad‑hoc basis.
  • Develop educational resources for workforce members on key billing, coding, and documentation topics.
• Policy and Procedures
  • Develop and review company policies and procedures on a regular and ad‑hoc basis related to billing and coding compliance.
• Special Projects
  • Participate in special compliance projects, including process optimization efforts.
  • Treat patients and coworkers consistent with the Next Care Mission Statement, Vision, Values and Performance Standards.
  • Perform other related duties as assigned or described in company policy.

• Education:
  
  Bachelor's Degree preferred, or equivalent combination of education, training, and experience.
• Certification:
  Professional coding certification or completion of a medical coding training program, or equivalent combination of education, training, and experience.
• Working Knowledge of:
  Medical Coding, Microsoft Office Suite.
• Skills:
  
  Ability to communicate with others, ability to work as a team and independently, attention to detail, strong organizational and follow‑up skills, strong sense of ethics and leadership, ability to perform with professionalism and integrity.

• Experience:
  
  prior billing, coding, and documentation monitoring and audit experience; prior workforce coding education experience.

REPORTING TO THIS POSITION: N/A

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.

While performing the essential functions of this job, the employee is occasionally required to stand; walk; sit; lift; carry; use hands to handle or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop; kneel, crouch or crawl, talk, hear and lift and/or move up to 40 pounds.

While performing the essential functions of this job, the employee comes in contact with patient in a wide variety of circumstances. The employee may be exposed to unpleasant situations including accidents, injuries, illnesses, patient elements and varying or unpredictable situations.