Compliance Specialist Senior, Hospital Billing

4 weeks ago

Milwaukee, United States Advocate Health Full time

Supports Compliance Officers with the facilitation and administration of compliance activities related to the operation of the compliance program. Performs reviews, data analysis and investigations, tracks and analyzes compliance activities, and provides compliance and regulatory education and training. Note: this role will focus on Hospital Billing.

Major Responsibilities:

  • Leads the maintenance, execution and documentation of the annual compliance review plan.
  • Conducts or facilitates performance of reviews and investigations, including design and documentation of the review/investigatory methodology. Identifies potential compliance concerns, conducts data mining/analysis, compliance audits and investigations to confirm or refute concern, and quantifies the potential impact.
  • Performs data collection and analysis for investigations of potential compliance issues and for other compliance activities such as conflict of interest disclosures, risk assessments, surveys, responses to regulatory audits, compliance related lawsuits, etc. Uses analytical review, computer analytics and statistical sampling techniques to identify compliance risk areas.
  • Collaborates with various departments to obtain information needed in conducting reviews, risk assessments, and investigations. Provides result feedback summary reports to appropriate leadership and key stakeholders. Recommends corrective action plans in response to investigative findings and/or review results.
  • Partners with department leadership to establish compliance monitors and reports as needed. Provides feedback and education to providers, staff and leaders throughout the organization on the results of reviews, investigations, and monitoring activities.
  • Prepares quarterly reports for compliance committees regarding the compliance review activities and actions taken, and creates reports for regulatory agencies as directed.
  • Develops department policies, procedures and tools for effective data mining, implementation of compliance reviews and audits, and investigation plans and reporting of results.
  • Manages special and complex project work, researching key project components and designing the internal/review process and corresponding documentation.
  • Functions as a knowledgeable resource for identifying current and ongoing changes to applicable laws, rules, regulations and policies related to compliance activities.
  • Trains new staff on data mining, auditing and investigation processes, and develops educational tools to promote efficiency and accuracy.


Licensure, Registration, and/or Certification Required:

  • None Required.


Education Required:

  • Bachelor's Degree (or equivalent knowledge) in Health Information Management or related field.


Experience Required:

  • Typically requires 5 years of experience in a health care environment that includes experiences with health care regulatory requirements.


Knowledge, Skills & Abilities Required:

  • Working knowledge of compliance related regulations such as coding, billing, documentation requirements, Local and National Coverage Decisions, National Comprehensive Coding Initiatives, Medicare/Medicaid billing regulations, the HIPAA Privacy Rule, etc.
  • Strong computer, problem-solving and analytical skills, including ability to perform data mining to identify aberrant patterns that may be indicative of compliance issues or trends.
  • Ability to lead a team and problem solve complex compliance issues and data.
  • Ability to train and mentor staff and act as a resource on complex audits, reviews and investigations.
  • Highly motivated, team oriented, professional and trustworthy, with strong skills in personal diplomacy.
  • Presentation and writing skills to deliver and organize media for delivery of reports and education to physicians, leadership, and staff.
  • Demonstrated ability to handle sensitive communications with leadership, physicians, management, and legal counsel.
  • Experience with maintaining confidentiality of patient and business information.
  • Strong organizational and time management skills.
  • Demonstrated proficiency in the Microsoft office (Word, Excel, PowerPoint, Access) or similar products.


Physical Requirements and Working Conditions:

  • Must be able to drive to various sites so therefore will be exposed to weather and road conditions.
  • Operates all equipment necessary to perform the job.
  • Exposed to normal office environment.


This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.

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