Billing / Coding Compliance Specialist (5002)

This position has the primary function of coordinating and supporting the Deputy Chief Compliance Officer with administrative, analytical, and program coordination activities. This position will provide support related to compliance auditing activities and programs, assisting with developing and coordinating the Compliance Audit Plan, supporting proactive and reactive audits of professional fee billings in clinic and facility settings, including federally qualified health centers. Proactively support audit activities related to billing and coding risks to the SOM, identifying and calculating potential overpayments based on audit results, participating in the repayment process if necessary, reviewing research billing compliance issues and assisting the Deputy Chief Compliance Officer in designing and managing a comprehensive billing/auditing program. 

The position supports compliance-related activities by gathering information, coordinating documentation reviews, monitoring follow-up actions, and preparing materials under the direction of the Deputy Chief Compliance Officer. This role does not independently determine compliance findings or regulatory interpretations, but works within established guidance and supervisory direction.

This position will administratively report to the Deputy Chief Compliance Officer who reports to the Chief Compliance Officer who reports to the Dean and Provost of the SOM.  This position will work closely with the other staff members in the Office of Compliance and Ethics, academic and administrative departments/ units of the SOM and SIU HealthCare.  

Administration:  100%

1. Assist with the development and execution of the Annual Compliance Audit Plan as part of the Annual Compliance Work Plan. Identify areas of regulatory audit risk based on regulatory guidance and industry enforcement trends. Track audit schedules, maintain documentation, and support audit logistics.

2. Audit clinical services based on standardized coding systems such as CPT/HCPC billing codes or ICD-10 diagnosis codes under established protocols and supervisory direction.
3. Apply Medicare, Medicaid, and third-party payer rules and regulations, sub-regulatory guidance, and when conducting chart reviews, billing audits, or providing guidance to SOM staff; escalating questions or concerns to the Deputy Chief Compliance Officer as appropriate.
4. Conduct proactive and reactive audits to confirm adequacy of the documentation relative to billing compliance requirements.

5. Prepare written audit report and assist in the development of training and education for Patient Business Services, Physicians, Advanced Practice Providers, Leaders, and others as appropriate or requested.  

6. Assist in the implementation, training, and monitoring of compliance policies and operating procedures related to billing compliance.

7. Prepare reports for the Executive Compliance Committee and/or senior management at the SOM and SIU HC for review by compliance leadership. Report on key findings to the Executive Compliance Committee.

8. Participate as a member of various committees or working groups focused on billing compliance and compliance risk assessment activities to support compliance leadership. 
9. Assist in the development and presentation of education modules/programs for billing providers, medical residents, and staff members related to the Compliance Work Plan, or, audit results. 

10. Maintain reference materials related to billing compliance laws, regulations, and guidelines. Partner with Patient Business Services, Coding and other related teams to provide communication, guidance and education to Physicians, Advanced Practice Providers, et al.