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Description

Job Summary

Reporting to the Corporate Director, Compliance and Audit Operations, the Senior Manager, Compliance and Audit Operations provides operational leadership and oversight for audit, monitoring, and education activities related to hospital and professional billing, coding, and documentation compliance.

This role ensures Compliance and Audit Partners execute high-quality audits using consistent methodologies and deliver timely, accurate, and actionable results. The Senior Manager partners closely with the Corporate Director to support investigations, compliance inquiries, and strategic initiatives while ensuring alignment with regulatory standards and organizational compliance objectives.

Principal Duties and Responsibilities:

Oversight & Leadership

Provides direct operational leadership and guidance to Compliance and Audit Partners responsible for professional and facility-based services.

Ensures consistent audit standards, methodologies, documentation, and alignment with established compliance strategies.

Oversees execution of audits, monitoring, and education activities to confirm compliance, identify reimbursement implications, and communicate risk areas.

Supports investigations, compliance inquiries, and strategic initiatives to ensure timely completion and appropriate follow-up actions.

Manages staff responsible for focused coding and billing compliance audits and special projects included in the annual departmental work plan.

Program Oversight & Policy Support

Evaluates billing and coding compliance activities to assess effectiveness and ensure appropriate coverage of risk areas.

Provides operational guidance for policies, workflows, and processes supporting compliant documentation, professional billing, and coding practices.

Leads review and updating of billing and coding compliance policies in collaboration with the Corporate Director.

Communicates applicable policies and supports operational implementation.

Audit Program Management

Assists in preparation and execution of the billing and coding components of the Compliance Work Plan.

Directs focused audits and reviews to assess adherence to billing compliance policies and regulatory standards.

Oversees sample reviews to confirm billed codes are supported by documentation.

Ensures audit reports are accurate, clear, and actionable.

Education & Collaboration

Oversees development and delivery of coding and billing compliance education programs.

Ensures communication of audit findings, trends, and risk areas to providers and departments.

Serves as an advisor to clinical and administrative departments regarding compliance risks.

Supports corrective action recommendations when appropriate.

Data Analysis & Reporting

Oversees analysis of medical record documentation and billing data for audits.

Maintains reporting mechanisms providing insights into audit activity and compliance trends.

Minimum Qualifications:

Education
- Bachelor's degree required.
Experience
- Minimum seven (7) years of audit experience required.
- Minimum five (5) years of hospital/clinical coding and billing management experience required.
- Experience with ICD-10, CPT, and HCPCS coding in multi-specialty professional and hospital/clinical billing environments required.
- Proficiency in MDAudit Enterprise software and Epic electronic health record systems required.
Certification
- Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) required.

Knowledge, Skills, and Abilities:

Minimum KSAs

Knowledge of billing, coding, and documentation requirements, including Federal and State regulations, medical necessity standards, and professional billing practices.
Knowledge of legal and regulatory compliance requirements related to coding, billing, and documentation.
Thorough understanding of coding documentation improvement practices.
Ability to clearly communicate audit findings and coding compliance information.
Strong root cause analysis and critical thinking skills.
Strong interpersonal and written communication skills.
Strong organizational skills and attention to detail.
Ability to manage deadlines and multiple concurrent audit initiatives.
Working knowledge of Microsoft Office applications (Word, Excel, PowerPoint) and Epic EMR systems.
Ability to work effectively in a matrixed environment and adapt to change.

Preferred KSAs

Knowledge of healthcare financial management principles and reimbursement methodologies.
Advanced project management skills.
Experience analyzing claims data and interpreting audit analytics tools.
Experience working within the MD Audit tool.
Ability to influence stakeholders and drive adoption of corrective action plans at the department or service-line level.

Preferred Qualifications:

Clinical background (e.g., LPN, RN).
Certification in Health Care Compliance (CHC).
Project management experience.
Experience working in MD Audit tool.

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