Billing Compliance Analyst

JOB SUMMARY:

Works under minimal supervision to manage and perform billing compliance reviews of professional billing, hospital billing, or research billing functions and activities of UTHSCT. Conducts complex billing reviews for physician and hospital to determine departmental/unit/program adherence to compliance with established billing, coding and other federal and state billing compliance regulations. Review and analyze medical records, claims and workflow processes to ensure accuracy, completeness, and compliance with regulatory requirements. The primary goal is to improve the quality of clinical documentation, which plays a crucial role in patient care, compliance, billing, coding, and reimbursement processes.

MAJOR RESPONSIBILITIES / DUTIES / CRITICAL TASKS:

• Conducts complex reviews of Physician Practice Plan and University Hospital billing compliance activities in accordance with applicable laws, regulations, rules or policies.

• Using audit tools, authoritative references, CMS and CPT guidelines, bell curves, etc. to analyze for trends, audit providers and coders, and provide education/feedback individually or in a group setting.

• Conducts prospective and retrospective inpatient and outpatient documentation audits to confirm compliance with documentation and billing rules and regulations set forth by the Centers for Medicare and Medicaid Services (CMS), Medicare carrier and Fiscal Intermediary, State regulations and Institutional policies.

• Maintains a thorough understanding of CPT, ICD-10-CM, and HCPCS coding principles, governmental regulations, and third party guidelines regarding documentation and/or billing compliance.

• Responsible for reviewing and preparing appropriate reports for the Physician’s Advisory Council, Executive Compliance Committee, and UT System as needed.

• Serves as billing compliance liaison between UT Tyler School of Medicine, Clinical Faculty Practice Plan and Ardent corporate leadership.

• Interface with revenue cycle business partner (Ensemble) as needed.

• Provides new provider medical billing orientation as well as continuing provider education in medical billing compliance as well as ongoing education of medical residents.

ACCOMPANYING KNOWLEDGE, SKILLS, ABILITIES AND COMPETENCIES:

• Knowledge of health care regulations and standards as they apply to correct coding.

• Understands regulatory and organizational guidelines and remains aware of changes in the healthcare environment

• Ability to provide standard documentation on education feedback to providers in a timely manner.

• Ability to perform a trend analysis of provider's bell curves and pull reports accordingly.

• Ability to do independent education, research, and analysis.

• Flexibility to audit specific service lines as needed.

• Ability to communicate effectively and professionally via email, phone, or Teams messages.

• Computer literacy – Microsoft Office (Word, Excel, Outlook, Teams), Adobe, MD Audit.

• Familiarity and working knowledge of electronic medical record environments.

• Maintains a professional and cooperative attitude with providers, co-workers, and employees.

• Ability to work as part of a team, both internally and with health care partners.

REQUIRED EDUCATION / EXPERIENCE:

• Bachelor’s degree required.

• Five (5) years of related experience required.

• May accept a combination of education and experience.

REQUIRED CERTIFICATIONS / LICENSES:

• Must be certified as Certified Professional Coder (CPC/CPC-H) by the American Academy of Professional Coders or be a Registered Health Information Administrator (RHIA), or a Certified Coding Specialist (CCS/CCS- P) by the American Health Information Management Association.

• Certified Professional Medical Auditor (CPMA) or Certified Healthcare Chart Auditor (CHCA) credentials preferred. Must obtain CPMA, CHCA, or similar certification as approved by supervisor within one (1) year of employment in this role.