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Director of HB and PB Compliance

Company: The Wilshire Group
Location: Palo Alto
Posted on: May 31, 2024

Job Description:

Wilshire hires only the brightest and most experienced professionals in the healthcare revenue cycle management industry. Wilshire will take the time to get know you and your employment history. We will then place you in a role that will lead to a path of career success. About The Wilshire Group -The Wilshire Group, a renowned boutique consulting firm in Los Angeles, specializes in revenue cycle optimization and fostering effective collaboration between operational and IT facets. With a robust track record of aiding over 100 healthcare systems nationwide, our team thrives on professionalism, efficiency, and adaptability.Our core values- professionalism, efficiency, and flexibility- underscore our commitment to creating an inclusive and dynamic workplace. We embrace diverse narratives and believe in offering opportunities to exceptional individuals who bring their best to the table.We are currently offering a contracted interim position at one of US News Best Hospitals 2022-23. This position caters to top performers seeking a professional environment that acknowledges and values their dedication and proficiency. While this role doesn't offer benefits, it presents an opportunity to work within an organization that encourages talented individuals to surpass conventional boundaries.Join us at The Wilshire Group, a place where talented professionals find a home to showcase their skills and contribute meaningfully to the healthcare landscape.Why Wilshire? Employee Testimonial"The number of RCM subject matter experts I get to work with each day is unreal. Working alongside and as part of this team -to help shape the RCM space is exciting."-Patti Consolver, Director of Business Development -This is a contracted position for 6+ months. This position offers 65% of fee sharing. Equivalent to $95-$110 per hour.Responsibilities:
Works in close collaboration with the Chief Compliance Officer design and oversees the strategic direction and goal-setting for
Compliance Billing Integrity operations and ensure the s development of outcome programs to support the direction of the organization.
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Oversees the direction and management of Compliance Billing Integrity operations for hospital billing integrity and physician
billing integrity programs, including strategic planning, process improvement, change management, and oversight of audits,
education and training; leads confidential and complex investigations of potential billing errors and billing fraud.
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Compiles, analyzes and integrates data and metrics for continuous improvement of the Compliance Billing Integrity programs,
coordination and efficient performance of Compliance Billing Integrity initiatives, development and implementation of tools,
forms, and educational materials to improve organizational billing integrity performance.
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Oversees Compliance preparedness for billing integrity regulatory scrutiny in accordance with laws, regulations, billing
manuals, documentation and coding rules, and principles of false claims and fraud, waste, and abuse; directs operational
activities of the Compliance Billing Integrity program relating to compliance with federal and state laws and regulations foraccurate facility and professional billing.
Develops and oversees compliance billing integrity standards, policies, procedures, and practices; oversees the direction,
implementation and sustainment of Compliance Billing Integrity programs and documentation that demonstrate an
organizational-wide billing integrity program.
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Identifies and manages metrics and performance goals for the Compliance Billing Integrity team; sets metrics for each level of
staff and team performance; establishes criteria for reporting to support day-to-day program management; establishes and
maintains metrics to demonstrate progress towards goals and effectiveness of the Compliance Billing Integrity program;
works continuously to improve the Compliance Billing Integrity program.
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Ensures the development, implementation, improvement, and sustainability of comprehensive Compliance Billing Integrity
audit plans, including hospital fee audits, professional services audits, routine and focused audits, proactive and reactive
audits; develops and executes a comprehensive annual audit plan.
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Manages and resolves responses to government documentation, coding, and billing audits; responds to alleged violations of
documentation, coding, and billing rules, regulations, policies, and procedures.
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Oversees the direction and management of partnerships with numerous entities and stakeholders, including Stanford Health
Care, Lucile Packard Children's Hospital Stanford, University Healthcare Alliance, Packard Children's Health Alliance,
ValleyCare Hospital, the School of Medicine, faculty physicians, Department Chairs, and Division Chiefs; develop and
maintains reports for the various entities' senior leaders and the Board of Directors.
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Oversees the direction and management of Compliance Billing Integrity resources, including education, training, awareness,
guidance, learning aids, websites, and other resources.
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Oversees and directs proactive Compliance Billing Integrity programs to detect and prevent compliance risks; assesses
organizational systems to determine gaps in compliance billing integrity and determine opportunities for remediation; leads
and manages efforts to identify potential compliance billing integrity issues and areas of compliance billing integrity
vulnerability and risk; evaluates and executes compliance billing integrity risk mitigation plans and corrective action plans.
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Obtains sufficient, competent, and relevant regulatory documentation to afford a reasonable basis for analysis, judgment and
conclusions; stays current with applicable government rules and regulations; maintains current compliance billing integrity
resources and information.
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--- Works collaboratively with leadership to foster a culture of billing integrity throughout the organizationExperience Qualifications:--- Thirteen (13) years of directly related work experience in the specialty area assignedRequired Knowledge, Skills and Abilities:--- Ability to maintain competence in and up-to-date knowledge of healthcare compliance requirements, practices and trends.
--- Ability to maintain confidentiality of sensitive information.
Ability to model and demonstrate consistently high standards of professional ethics, integrity and trust Ability to perform
research and analysis of health care laws, regulations and policies as well as compliance issues.

--- Ability to plan, organize, motivate, mentor, direct and evaluate the work of others.
--- Ability to plan, organize, prioritize, work independently and meet deadlines.
--- Ability to solve problems and identify solutions.
Ability to understand, interpret and apply complex federal and state hospital compliance laws, rules, regulations and
guidelines.

--- Demonstrated ability to use judgment and make sound decisions.
--- Knowledge of and ability to research laws, regulations and billing rules, including CMS manuals and Medi-Cal rules.
Knowledge of hospital/technical and professional services reimbursement systems (OPPS, IPPS, Professional fee, Medicare,
Medi-Cal and other appropriate payment systems).

--- Knowledge of labor relations; economics; legislation affecting hospital administration, and compliance integrity programs.
--- Knowledge of organization and functioning of hospitals, emergency departments and ambulatory care clinics.
Knowledge of principles and practices of organization, administration, fiscal and personnel management Knowledge of
revenue cycle and charge description master and identification of risks of and opportunities for charge capture.

--- Knowledge of theories, principles and practices of strategic planning, program evaluation and improvement.
Education:
Bachelors required, Master's Degree preferred in a relevant field of work and 7+ years of Health Care experience, or equivalent combination of Education/Experience. Strong computer skills including Word, Excel, and PowerPoint is required.

Experience:
The individual must be able to demonstrate supervisory skills appropriate for the management of a team of application analysts in a revenue environment. Experience with Electronic Health Records, Revenue cycle and Software Implementation required.Project Management (50%):

  • Training and Education
  • Reporting and Communication
  • Monitoring and Auditing
  • Documentation and Record Keeping
  • Rebilling Process
  • Enhanced Technological Utilization for Audit Tracking and Management -
  • Other areas as requested -Wilshire is honored that you have taken the time to review/apply to our open position. We will now take the time to review your experience and be in touch with you soon. How many years of Epic experience do you have? -*
    -- Do you currently work in an inpatient hospital setting? -*
    -- For government reporting purposes, we ask candidates to respond to the below self-identification survey.Completion of the form is entirely voluntary. Whatever your decision, it will not be considered in the hiringprocess or thereafter. Any information that you do provide will be recorded and maintained in aconfidential file.As set forth in The Wilshire Group's Equal Employment Opportunity policy,we do not discriminate on the basis of any protected group status under any applicable law.If you believe you belong to any of the categories of protected veterans listed below, please indicate by making the appropriate selection.As a government contractor subject to the Vietnam Era Veterans Readjustment Assistance Act (VEVRAA), we request this information in order to measurethe effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. Classification of protected categoriesis as follows:A "disabled veteran" is one of the following: a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a person who was discharged or released from active duty because of a service-connected disability.A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.An "Armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.Voluntary Self-Identification of Disability Form CC-305 Page 1 of 1 OMB Control Number 1250-0005 Expires 04/30/2026 Voluntary Self-IdentificationFor government reporting purposes, we ask candidates to respond to the below self-identification survey.Completion of the form is entirely voluntary. Whatever your decision, it will not be considered in the hiringprocess or thereafter. Any information that you do provide will be recorded and maintained in aconfidential file.As set forth in The Wilshire Group's Equal Employment Opportunity policy,we do not discriminate on the basis of any protected group status under any applicable law. Gender Please select Gender Are you Hispanic/Latino? Please select Are you Hispanic/Latino? Race & Ethnicity Definitions If you believe you belong to any of the categories of protected veterans listed below, please indicate by making the appropriate selection.As a government contractor subject to the Vietnam Era Veterans Readjustment Assistance Act (VEVRAA), we request this information in order to measurethe effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. Classification of protected categoriesis as follows:A "disabled veteran" is one of the following: a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or a person who was discharged or released from active duty because of a service-connected disability.A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.An "Armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985. Veteran Status Please select Veteran Status Voluntary Self-Identification of Disability Form CC-305 Page 1 of 1 OMB Control Number 1250-0005 Expires 04/30/2026
    Why are you being asked to complete this form?We are a federal contractor or subcontractor. The law requires us to provide equal employment opportunity to qualified people with disabilities. We have a goal of having at least 7% of our workers as people with disabilities. The law says we must measure our progress towards this goal. To do this, we must ask applicants and employees if they have a disability or have ever had one. People can become disabled, so we need to ask this question at least every five years.Completing this form is voluntary, and we hope that you will choose to do so. Your answer is confidential. No one who makes hiring decisions will see it. Your decision to complete the form and your answer will not harm you in any way. If you want to learn more about the law or this form, visit the U.S. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp .How do you know if you have a disability?A disability is a condition that substantially limits one or more of your "major life activities." If you have or have ever had such a condition, you are a person with a disability. Disabilities include, but are not limited to:
    • Alcohol or other substance use disorder (not currently using drugs illegally)
    • Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, HIV/AIDS
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    • Diabetes
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    • Epilepsy or other seizure disorder
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    • Intellectual or developmental disability
    • Mental health conditions, for example, depression, bipolar disorder, anxiety disorder, schizophrenia, PTSD
    • Missing limbs or partially missing limbs
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    • Traumatic brain injury Disability Status Please select Disability Status PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.
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Keywords: The Wilshire Group, Palo Alto , Director of HB and PB Compliance, Executive , Palo Alto, California

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