SUMMARY:

The Compliance Senior Manager has a broad understanding of billing compliance as it relates to Private Payer, Federal and State regulations and ensures that all genetic test coding and reimbursement practices, clinical documentation monitoring, reviews, education and training are in full compliance with regulations. The Compliance Senior Manager also has experience in general healthcare compliance matters, particularly as they relate to federal Medicare, Medicaid, Fraud, Waste and Abuse laws, including but not limited to OIG, Stark, and Anti-Kickback Statutes and all other applicable regulations, including the development of general compliance policies and procedures, training, and auditing.

KEY RESPONSIBILITIES*:

• Expands and develops all compliance program policies and employee training content with a particular focus on billing compliance and ensures successful execution for organization-wide compliance training.
• Ensures accurate coding of laboratory services according to CPT, HCPCS, ICD-10-CM guidelines, compliance department policies, and other corporate requirements.
• Performs monitoring activities including focused and general audits on all assigned areas based on risk profiles of the company. Maintains, communicates and executes a schedule of regular monitoring activities.
• Leads or participates in billing risk mitigation plans to address any identified compliance gaps.
• Supports the billing department with: CPT coding and billing reimbursement advice and assistance, government and commercial payer inquiries, internal audits, prepayment reviews and recoupments, management of 3rd party billing and coding audits, monitoring and analyzing trends in claim submissions to identify payment inconsistencies or errors and the corresponding corrective actions, and identification of areas where training and education are needed.
• Reviews and resolves compliance policy exception requests related to billing inconsistencies and errors from patients, customers, third-party institutions, and other team members.
• Conducts regulatory research to maintain expertise and support compliance training and education related to Federal, State and local laws and regulations, enforcement initiatives, third party coding, billing and claims submission, financial arrangements with physicians, conflicts of interest and internal policies and procedures.
• Promotes compliance initiatives and awareness throughout GeneDx. Works with the Compliance and the Executive Leadership teams in identifying areas where training and education are needed and develops appropriate materials and information to support the overall Compliance Program.
• Assists in cooperation with Federal and State regulators, legal entities, organization officers, or board of directors during compliance reviews or investigations.
• Develops, gains approval for and implements a range of general compliance policies and procedures, including annual revisions and tracking.
• Develops, implements and reviews for effectiveness general compliance employee training.
• Other duties as assigned by leadership.

*Note that this is not an exhaustive list; the employee will be responsible for other duties as assigned.

EDUCATION:

• Bachelor’s degree plus at least 3-5 years relevant work experience, Master's degree preferred.

EXPERIENCE:

• 5+ years’ experience with billing compliance management in a healthcare setting, preferably a genetic testing laboratory.
• Expertise with coding for genetic testing services using Next Generation Sequencing (NGS).
• Knowledge of state and federal Medicare, Medicaid, Fraud, Waste and Abuse laws, including but not limited to OIG, Stark, and Anti-Kickback Statutes and all other applicable regulations.
• Excellent written and oral communication skills.
• Strong work ethic with attention to detail.
• Ability to excel in a fast-paced and rapidly changing environment.
• Certified Professional Coder (CPC) and/or Certified in Healthcare Compliance (CHC) and/or other healthcare industry related credential preferred.