Senior Billing Compliance Reviewer

Job Ref:
47375

Location:
10 Brookline Place West, Brookline, MA 02445

Category:
Finance/Accounting

Employment Type:
Full time

Work Location:
Remote: 100% off site

Overview

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 will assist in the development and execution of the annual Billing Compliance work plan. They will monitor federal and state regulatory requirements and industry developments and work to determine applicability and risk to both technical and operational aspects of the organization. Metrics will be developed and reported quarterly. The Senior Reviewer will be expected to pursue successful completion of multiple tasks collaborating effectively with many departments 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 are united in our mission of conquering cancer, HIV/AIDS and related diseases. We strive to create an inclusive, diverse, and equitable environment where we provide compassionate and comprehensive care to patients of all backgrounds, and design programs to promote public health particularly among high-risk and underserved populations. We conduct groundbreaking research that advances treatment, we educate tomorrow's physician/researchers, and we work with amazing partners, including other Harvard Medical School-affiliated hospitals.

Responsibilities

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 new billing compliance guidelines, procedures and training programs designed to enhance the effectiveness of billing compliance program, including participation of personal development activities.
Attend and actively participate in various meetings which may include CPT-Epic, New Services, Regional Campuses, Inpatient Billing, ADCC and AAMC as well as other continuous quality improvement processes and workgroups as needed.
Serve as a liaison and collaborate with business partners (revenue cycle, nursing, clinical operations, HIS, ancillary departments, etc.).
Work with the educator to enhance existing training programs, documentation tools and tip sheets.
Special projects as assigned.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

Qualifications

Minimum Education:
High school diploma required. Bachelor’s degree preferred.

Minimum Experience:
5 years of experience in healthcare coding including at least 1 year of prior auditing experience. Knowledge of CMS (Medicare and Medicaid) and commercial payers billing and documentation guidelines, current coding resources, including CPT4, ICD-10-CM/PCS, HCPCS required.

License/Certification/Registration:
Required: Certified Coder (e.g., CCS, CPC, RHIT, or RHIA).
Preferred: CPMA (Certified Professional Medical Auditor) and/or CHC (Certified in Healthcare Compliance) or equivalent compliance certification.

KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED:
Strong interpersonal skills and collaborative mindset, including ability to establish and maintain effective relationships with providers, leadership, senior administration, colleagues, and billing compliance staff.
Excellent written and verbal communications, facilitation, and presentation skills used to share audit findings, risk areas and billing compliance issues identified, with ability to craft clear reports, present findings to clinical and executive audiences, and deliver effective education tailored to diverse stakeholders.
Ability to work independently with limited supervision and willingness to be flexible depending on department needs.
Ability to balance and manage multiple priorities and flexibility to reprioritize tasks when needed.
Knowledge of various audit software, Epic and/or other comparable software and database tools.
Knowledge of hospital operations, reimbursement, and applicable regulatory requirements.
Ability to present findings and discuss issues with providers and other staff confidentially and effectively.
Strong attention to detail and highly organized; ability to manage multiple audits and deadlines in a fast-paced, matrixed environment.
Sound judgment, integrity, and discretion in handling sensitive information and navigating complex compliance matters.
Strong team player with ability to work well independently and as a group.
Ability to work under pressure, multitask and meet deadlines.
Technical capability to utilize multiple information systems and Microsoft applications.
Knowledge of oncology-specific billing scenarios (e.g., infusion/chemotherapy, supportive care drugs, radiation therapy planning/delivery) preferred.

Pay Transparency Statement

The hiring range is based on market pay structures, with individual salaries determined by factors such as business needs, market conditions, internal equity, and based on the candidate’s relevant experience, skills and qualifications.

For union positions, the pay range is determined by the Collective Bargaining Agreement (CBA)

$94,900 - $105,700

At Dana-Farber Cancer Institute, we work every day to create an innovative, caring, and inclusive environment where every patient, family, and staff member feels they belong. As relentless as we are in our mission to reduce the burden of cancer for all, we are equally committed to diversifying our faculty and staff. Cancer knows no boundaries and when it comes to hiring the most dedicated and diverse professionals, neither do we. If working in this kind of organization inspires you, we encourage you to apply.

Dana-Farber Cancer Institute is an equal opportunity employer and affirms the right of every qualified applicant to receive consideration for employment without regard to race, color, religion, sex, gender identity or expression, national origin, sexual orientation, genetic information, disability, age, ancestry, military service, protected veteran status, or other characteristics protected by law.

EEOC Poster