Compliance Audit Manager - Coding and Billing

WHY UT SOUTHWESTERN?
With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and compassion. As a world-renowned medical and research center, we strive to provide the best possible care, resources, and benefits for our valued employees. Ranked as the No. 1 hospital in Dallas-Fort Worth according to U.S. News & World Report, we invest in you with opportunities for career growth and development to align with your future goals. Our highly competitive benefits package offers healthcare, PTO and paid holidays, on-site childcare, wage, merit increases and so much more. We invite you to be a part of the UT Southwestern team where you'll discover a culture of teamwork, professionalism, and a rewarding career! 

JOB SUMMARY
Works under minimal supervision reporting to the AVP of Compliance/Chief Compliance Officer, to perform assessments of risk related to health care reimbursement through third party payers, particularly Medicare, Medicaid, and other government payers, managed care payers, and the like. This role uses sources such as the OIG Work Plan, payer alerts, probe audits and internal reviews and reports from monitoring activities; methodologies such as probe auditing, statistical sampling and extrapolation; and technologies such as Microsoft Office (e.g., Excel), MDAudit, Med Analytics, electronic medical records, and other applicable tools and methodologies, to identify, quantify, and make recommendations regarding reimbursement errors and opportunities and corrective actions, for UTSW health care facilities and providers. Performs and /or manages various assurance activities to determine departmental/unit/program adherence to internal controls, education/training requirements and compliance with established policies and procedures.

Oversee coding and billing compliance activities to ensure adherence to federal and state regulations, payer requirements, and institutional policies. Manage and conduct risk-based audits of professional and facility billing, coding accuracy, documentation, and reimbursement practices. Supervise compliance staff, establish performance expectations, and ensure timely completion of audits, investigations, and advisory requests. Identify billing and coding risks, analyze trends, and recommend corrective actions to mitigate regulatory and financial exposure. Collaborate with Revenue Cycle, Clinical Departments, and operational leadership to address compliance concerns and strengthen internal controls. Oversee corrective action plans, including monitoring, validation, and reporting of remediation efforts. Provide guidance and education regarding Medicare, Medicaid, and other payer requirements, including documentation, coding, and billing standards.
 

BENEFITS
UT Southwestern is proud to offer a competitive and comprehensive benefits package to eligible employees. Our benefits are designed to support your overall wellbeing, and include\:

• PPO medical plan, available day one at no cost for full-time employee-only coverage
• 100% coverage for preventive healthcare-no copay
• Paid Time Off, available day one
• Retirement Programs through the Teacher Retirement System of Texas (TRS)
• Paid Parental Leave Benefit
• Wellness programs
• Tuition Reimbursement
• Public Service Loan Forgiveness (PSLF) Qualified Employer
• Learn more about these and other UTSW employee benefits!

EXPERIENCE AND EDUCATION

Required

• Education
  Bachelor's Degree in business or healthcare administration, regulatory compliance, consulting, project management, or related area. 
   

• Experience
  5 years progressively responsible related experience. 
   

Preferred

• Education
  Master's Degree in business or management. 
   

• Experience
  Knowledge of clinical trial billing and/or experience in reimbursement coding, auditing, and reporting. 
   

• Licenses and Certifications
  Current certifications in hospital and physician coding Upon Hire or
  Certified Healthcare Compliance (CHC) Upon Hire 
   

JOB DUTIES

• Manages auditing of reimbursement issues for UTSW health care providers and entities, including the claims incurred in UTSW hospitals and clinics, affiliate hospitals, ambulatory locations, and clinical trial billing.
• Assists the UTSW AVP of Compliance/Chief Compliance Officer in responding to third party payer audit requests as well as identifying and auditing significant reimbursement errors and opportunities, focusing on determination of error rates, mitigation strategies, makes recommendations for performance improvement. Provides compliance assistance to impacted providers and facilities with audit responses and activities, as appropriate.
• Works under the direction of the AVP of Compliance/Chief Compliance Officer to conduct or manage staff in performing audits and investigations. This includes developing and executing all phases of a plan of investigation; such as determining and documenting applicable payer requirements, locating, understanding, and analyzing data, information and records; auditing data; and drafting findings and conclusions.
• Recommends and documents appropriate corrective action or actions responsive to findings and conclusions. Consults with impacted provider or facility to assure concurrence and follow through.
• Recommends education and training topics to the Office of Compliance to improve performance and reduce reimbursement errors.
• Assists the AVP of Compliance/Chief Compliance Officer with tracking and disseminating relevant payer information regarding current/applicable billing and compliance requirements.
• Assists the AVP of Compliance/Chief Compliance Officer with development of meaningful metrics for constituents such as providers, facilities and leadership, regarding performance and compliance with reimbursement rules and regulations, contracts, etc.
• Ensures timely and consistent interpretation, follow through, and resolution of reported compliance concerns.
• As applicable and when requested, works with external or internal legal counsel, external auditors or consultants, to assure successful completion of projects related to health care reimbursement.
• Coordinates and collaborates with the Directors within the Office of Compliance (and their staffs) to assure auditing/monitoring activities are evidence-based, supported by metrics, and meet the requirements of compliance program effectiveness.
• Oversees designated compliance analyst staff.
• Identifies trends and makes recommendations to improve culture, increase transparency, build trust and/or achieve compliance plan goals.
• Designs and prepares statistical and analytical reports for UT System, Executive and other campus Compliance Committees, and UT System, as appropriate.
• Performs other duties as assigned

Knowledge, Skills and Abilities

• Work requires ability to evaluate data and determine compliance with rules and regulations.
• Work requires ability to perform accurate statistical analysis of claims data, using recognized tools such as RAT-STATS, and other statistical tools, to perform extrapolations and calculations of errors and opportunities in reimbursement.
• Work requires absolute integrity and discretion, the ability to sustain confidentiality (particularly when working under the direction of legal counsel under the attorney client privilege) and reliability.
• Work requires effective written and verbal communication skills
• Work requires excellent interview skills.
• Work requires skill in using spreadsheet applications, word processing, various technology solutions (e.g., MD Audit) and database computer applications.
• Work requires telephone and personal contact with all levels of internal and external personnel and organizations to obtain or provide information and explain facts, policies, and procedures relating to resolution of problems of a recurring but non-routine nature.
• Work requires the ability to code and interpret claims to third party payers, along with supporting documentation, remittance advices, and reimbursement received.
• Work requires the ability to work well with various providers, facilities, and their administrative staffs.
• Work requires working knowledge and ability to construe payer requirements for claims adjudication and payment.

PHYSICAL REQUIREMENTS/WORKING CONDITIONS

Physical Requirements

• Talking

Working Conditions

• Office Setting

Salary Information
Salary is commensurate with education, skills, and relevant experience.

SECURITY AND EEO STATEMENT

Security
This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information.

EEO
UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination, including discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status.
 

WHY UT SOUTHWESTERN?
With over 75 years of excellence in Dallas-Fort Worth, Texas, UT Southwestern is committed to excellence, innovation, teamwork, and compassion. As a world-renowned medical and research center, we strive to provide the best possible care, resources, and benefits for our valued employees. Ranked as the No. 1 hospital in Dallas-Fort Worth according to U.S. News & World Report, we invest in you with opportunities for career growth and development to align with your future goals. Our highly competitive benefits package offers healthcare, PTO and paid holidays, on-site childcare, wage, merit increases and so much more. We invite you to be a part of the UT Southwestern team where you'll discover a culture of teamwork, professionalism, and a rewarding career! 

JOB SUMMARY
Works under minimal supervision reporting to the AVP of Compliance/Chief Compliance Officer, to perform assessments of risk related to health care reimbursement through third party payers, particularly Medicare, Medicaid, and other government payers, managed care payers, and the like. This role uses sources such as the OIG Work Plan, payer alerts, probe audits and internal reviews and reports from monitoring activities; methodologies such as probe auditing, statistical sampling and extrapolation; and technologies such as Microsoft Office (e.g., Excel), MDAudit, Med Analytics, electronic medical records, and other applicable tools and methodologies, to identify, quantify, and make recommendations regarding reimbursement errors and opportunities and corrective actions, for UTSW health care facilities and providers. Performs and /or manages various assurance activities to determine departmental/unit/program adherence to internal controls, education/training requirements and compliance with established policies and procedures.

Oversee coding and billing compliance activities to ensure adherence to federal and state regulations, payer requirements, and institutional policies. Manage and conduct risk-based audits of professional and facility billing, coding accuracy, documentation, and reimbursement practices. Supervise compliance staff, establish performance expectations, and ensure timely completion of audits, investigations, and advisory requests. Identify billing and coding risks, analyze trends, and recommend corrective actions to mitigate regulatory and financial exposure. Collaborate with Revenue Cycle, Clinical Departments, and operational leadership to address compliance concerns and strengthen internal controls. Oversee corrective action plans, including monitoring, validation, and reporting of remediation efforts. Provide guidance and education regarding Medicare, Medicaid, and other payer requirements, including documentation, coding, and billing standards.
 

BENEFITS
UT Southwestern is proud to offer a competitive and comprehensive benefits package to eligible employees. Our benefits are designed to support your overall wellbeing, and include\:

• PPO medical plan, available day one at no cost for full-time employee-only coverage
• 100% coverage for preventive healthcare-no copay
• Paid Time Off, available day one
• Retirement Programs through the Teacher Retirement System of Texas (TRS)
• Paid Parental Leave Benefit
• Wellness programs
• Tuition Reimbursement
• Public Service Loan Forgiveness (PSLF) Qualified Employer
• Learn more about these and other UTSW employee benefits!

EXPERIENCE AND EDUCATION

Required

• Education
  Bachelor's Degree in business or healthcare administration, regulatory compliance, consulting, project management, or related area. 
   

• Experience
  5 years progressively responsible related experience. 
   

Preferred

• Education
  Master's Degree in business or management. 
   

• Experience
  Knowledge of clinical trial billing and/or experience in reimbursement coding, auditing, and reporting. 
   

• Licenses and Certifications
  Current certifications in hospital and physician coding Upon Hire or
  Certified Healthcare Compliance (CHC) Upon Hire 
   

JOB DUTIES

• Manages auditing of reimbursement issues for UTSW health care providers and entities, including the claims incurred in UTSW hospitals and clinics, affiliate hospitals, ambulatory locations, and clinical trial billing.
• Assists the UTSW AVP of Compliance/Chief Compliance Officer in responding to third party payer audit requests as well as identifying and auditing significant reimbursement errors and opportunities, focusing on determination of error rates, mitigation strategies, makes recommendations for performance improvement. Provides compliance assistance to impacted providers and facilities with audit responses and activities, as appropriate.
• Works under the direction of the AVP of Compliance/Chief Compliance Officer to conduct or manage staff in performing audits and investigations. This includes developing and executing all phases of a plan of investigation; such as determining and documenting applicable payer requirements, locating, understanding, and analyzing data, information and records; auditing data; and drafting findings and conclusions.
• Recommends and documents appropriate corrective action or actions responsive to findings and conclusions. Consults with impacted provider or facility to assure concurrence and follow through.
• Recommends education and training topics to the Office of Compliance to improve performance and reduce reimbursement errors.
• Assists the AVP of Compliance/Chief Compliance Officer with tracking and disseminating relevant payer information regarding current/applicable billing and compliance requirements.
• Assists the AVP of Compliance/Chief Compliance Officer with development of meaningful metrics for constituents such as providers, facilities and leadership, regarding performance and compliance with reimbursement rules and regulations, contracts, etc.
• Ensures timely and consistent interpretation, follow through, and resolution of reported compliance concerns.
• As applicable and when requested, works with external or internal legal counsel, external auditors or consultants, to assure successful completion of projects related to health care reimbursement.
• Coordinates and collaborates with the Directors within the Office of Compliance (and their staffs) to assure auditing/monitoring activities are evidence-based, supported by metrics, and meet the requirements of compliance program effectiveness.
• Oversees designated compliance analyst staff.
• Identifies trends and makes recommendations to improve culture, increase transparency, build trust and/or achieve compliance plan goals.
• Designs and prepares statistical and analytical reports for UT System, Executive and other campus Compliance Committees, and UT System, as appropriate.
• Performs other duties as assigned

Knowledge, Skills and Abilities

• Work requires ability to evaluate data and determine compliance with rules and regulations.
• Work requires ability to perform accurate statistical analysis of claims data, using recognized tools such as RAT-STATS, and other statistical tools, to perform extrapolations and calculations of errors and opportunities in reimbursement.
• Work requires absolute integrity and discretion, the ability to sustain confidentiality (particularly when working under the direction of legal counsel under the attorney client privilege) and reliability.
• Work requires effective written and verbal communication skills
• Work requires excellent interview skills.
• Work requires skill in using spreadsheet applications, word processing, various technology solutions (e.g., MD Audit) and database computer applications.
• Work requires telephone and personal contact with all levels of internal and external personnel and organizations to obtain or provide information and explain facts, policies, and procedures relating to resolution of problems of a recurring but non-routine nature.
• Work requires the ability to code and interpret claims to third party payers, along with supporting documentation, remittance advices, and reimbursement received.
• Work requires the ability to work well with various providers, facilities, and their administrative staffs.
• Work requires working knowledge and ability to construe payer requirements for claims adjudication and payment.

PHYSICAL REQUIREMENTS/WORKING CONDITIONS

Physical Requirements

• Talking

Working Conditions

• Office Setting

Salary Information
Salary is commensurate with education, skills, and relevant experience.

SECURITY AND EEO STATEMENT

Security
This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information.

EEO
UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination, including discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status.