Billing 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.

CREDENTIALS TO BE VERIFIED BY PLACEMENT OFFICER

• Bachelor's degree in Health Information Management (HIM), Healthcare Administration, Medical Coding, Business Administration, Public Administration, Healthcare Management, or related field with coursework relating to healthcare operations includes the following topics: Medical Terminology, Human Anatomy and Physiology, ICD-10 Coding, and CPT Coding, or closely related courses.
• A total of 1 year work experience in a healthcare setting (i.e., hospital, physician's office, nursing home, billing agency) utilizing ICD-10, and CPT coding systems, Healthcare Common Procedure Coding System (HCPCS), and the Current Procedural Terminology (CPT) systems of coding to assign codes for services provided to patients.
• Any one of the following certifications: Certified Professional Coder-Apprentice (CPC-A), Certified Professional Coder (CPC) or a Certified Outpatient Coder (COC) by the American Academy of Professional Coders (AAPC) (formerly CPC-H certification) or current certification as a Certified Coding Associate (CCA), Certified Coding Specialist (CCS) or Certified Coding Specialist-Physician-based (CCS-P) or Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) by the American Health Information Management Association (AHIMA).

Note: Master's Degree in an area consistent with the duties of the position may be substituted for one (1) year of work experience.

Knowledge, Skills and Abilities (KSAs)

1. Knowledge of principles and methods for curriculum and training design, teaching and instruction for individuals and groups, and the measurement of training effects
2. Knowledge of business and management principles involved in strategic planning, resource allocation, human resources modeling, leadership technique, production methods, and coordination of people and resources
3. Skill in analyzing information and evaluating results to choose the best solution and solve problems.
4. Skill in scheduling events, programs, and activities, as well as the work of others.
5. Skill in oral and written communication
6. Ability to adjust actions in relation to others' actions.
7. Ability to listen to and understand information and ideas presented through spoken words and sentences
8. Ability to apply general rules to specific problems to produce answers that make sense
9. Ability to develop goals and plans to prioritize, organize, and accomplish work.
10. Ability to work effectively with staff, the public, and outside constituency groups
11. Ability to effectively plan, delegate, and supervise the work of others.
12. Ability to utilize various computer software packages, such as Accounting Software, query, etc.
13. Ability to work independently and exercise judgment in order to be able to analyze and investigate a variety of questions or problems
14. Ability to analyze and develop guidelines, procedures and systems

Condition of Employment
Pursuant to the State Universities Civil Service System, an out-of-state resident who is hired into this positionmust establish Illinois residency within 180 calendar days of their start date.

Internal Number: 5276721