niramedical - Quality Assurance & Compliance Manager
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Requirements
• 7+ years of progressive experience in healthcare revenue integrity, auditing, compliance, or quality management. • Demonstrated experience designing and implementing structured QA/QC or revenue integrity programs in multi-site healthcare environments. • Advanced knowledge of CMS billing regulations, MAC LCD/NCD policies, Commercial payer reimbursement structures, CPT/HCPCS coding standards, Modifier compliance logic, and FDA Indications & Medical Necessity requirements • Experience in managing audit documentation, corrective action workflows, and compliance governance. • Strong analytical capability with the ability to interpret complex billing data and regulatory guidance. • Executive-level written and verbal communication skills. • CPC, CPMA, RHIA, RHIT, or equivalent certification. • Experience within neurology, infusion therapy, specialty pharmaceuticals, or other high-complexity service lines. • Experience in MSO or multi-practice healthcare platforms.
Responsibilities
• Enterprise Quality Program Leadership • Design and implement a comprehensive QA/QC framework across all service lines and practice locations. • Establish formal audit standards and inspection protocols. • Define quality control checkpoints within revenue cycle workflows. • Develop structured sampling methodologies and risk-based audit prioritization. • Lead quality validation efforts during new service implementation, onboarding, and system transitions. • Audit Execution & Compliance Oversight • Conduct and oversee structured audits of: • CPT/HCPCS coding accuracy • Modifier integrity • Diagnosis alignment • Medical necessity compliance • Drug billing and unit accuracy • Pre-release claim validation • Identify systemic risk patterns through denial and scrub trend analysis. • Issue formal findings and manage corrective and preventive action plans. • Monitor remediation efforts and validate sustained improvement. • Billing Governance & Policy Control • Develop and maintain centralized billing guide governance with formal version control. • Monitor and integrate CMS updates, MAC LCD/NCD revisions, and commercial payer policy changes. • Establish documentation control standards to ensure audit defensibility. • Align billing standards consistently across all sites. • Regulatory & Audit Readiness • Maintain structured audit documentation, inspection logs, and compliance reports. • Ensure readiness for Medicare audits, RAC reviews, and commercial payer investigations. • Develop formal audit response frameworks and documentation protocols. • Conduct risk assessments to evaluate compliance exposure across service lines. • Provide monthly and quarterly quality reporting to Revenue Cycle leadership. • Identify measurable opportunities for revenue protection and risk mitigation. • Ability to travel up to 25% as needed to conduct site level audits, compliance reviews, and workflow validations across multi-site operations.
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