Authorization and Compliance Manager

Job Overview:
EPC Billing is seeking a diligent and experienced Authorization and Compliance Manager to oversee the critical processes of obtaining prior authorizations and ensuring regulatory compliance within our organization. This role combines responsibility for securing insurance approvals for Substance Abuse and Mental Health services and maintaining strict adherence to healthcare regulations, including HIPAA. The Authorization and Compliance Manager will play a key role in minimizing claim denials and ensuring compliance with payer and legal requirements.

Key Responsibilities:

• Manage the prior authorization process for Substance Abuse and Mental Health programs, ensuring all necessary approvals are secured from insurance companies before services are rendered.
• Verify patient insurance coverage and eligibility for services, working closely with payers to resolve any issues.
• Ensure compliance with federal, state, and local regulations, including HIPAA, to protect patient privacy and ensure accurate billing.
• Conduct internal audits to review billing practices and compliance with legal requirements, ensuring the accuracy and integrity of all billing operations.
• Manage the provider credentialing and re-credentialing process with insurance companies, ensuring all required documentation is submitted and approved.
• Stay current on regulatory updates, payer rules, and compliance trends within the healthcare billing industry.
• Develop and implement compliance policies and procedures to maintain a high level of regulatory adherence throughout the organization.
• Train and educate staff on compliance requirements and authorization procedures, ensuring that all team members are well-versed in the latest regulations.
• Collaborate with the Billing and Claims Manager to address any compliance-related issues and improve billing processes.
• Handle any compliance investigations or inquiries and work with external regulatory bodies as needed.

Qualifications:

• Minimum of 3-5 years of experience in healthcare billing with a strong focus on authorizations and regulatory compliance, particularly for Substance Abuse and Mental Health programs.
• In-depth understanding of payer requirements, prior authorization processes, and regulatory standards such as HIPAA.
• Experience with provider credentialing processes and working with insurance companies to resolve coverage issues.
• Strong organizational and analytical skills, with the ability to conduct thorough audits and ensure compliance with regulations.
• Excellent communication and problem-solving skills, with the ability to manage payer relationships and collaborate with internal teams.
• Familiarity with medical billing software, such as Collaborative MD KIPU or Kareo, is preferred.

Education:

• High School Diploma or equivalent required; associate’s or bachelor’s degree in healthcare administration, compliance, or a related field preferred.
• Certification in healthcare compliance (e.g., CHC) is a plus.

Job Type: Full-time

Benefits:

• Paid time off

Schedule:

• Monday to Friday

Ability to Relocate:

• Braintree, MA 02184: Relocate before starting work (Required)

Work Location: In person