Responsibilities
- Independently determine PBB eligibility for new and existing clinic locations through financial, administrative, and operational integration assessments.
- Lead completion of CMS PBB Attestation for all hospital-owned clinics and facilities, and ensure audit-ready documentation, including ownership evidence, integration details, organizational charts, and shared service descriptions for all hospital clinics and facilities.
- Conduct scheduled annual compliance reviews to ensure continued compliance with CMS regulations.
- Validate the accuracy of PECOS enrollment for all hospital facilities and ensure alignment of provider-based designation with CMS Cost Reporting and Pharmacy 340B submissions.
- Monitor regulatory updates, assess organizational impact, and communicate changes to key stakeholders.
- Conduct financial modeling for PBB conversions, estimating facility fee revenue and payer-specific reimbursement.
- Analyze expected vs. actual revenue performance for all PBB locations and identify root causes of variances.
- Develop recurring reports and dashboards to track financial performance trends across the PBB portfolio.
- Facilitate cross-functional Medicare HB Reconciliation Workgroup to identify root cause and resolve hospital billing issues related to provider-based billing.
- Collaborate with Finance, Revenue Integrity, and Ambulatory Operations to validate assumptions and ensure accurate financial forecasting.
- Responsible for the accuracy of Epic configuration requirements for PBB designation, acting as the central liaison between Operations, Finance, Revenue Cycle, and IT.
- Conduct routine audits to ensure correct utilization of PBB logic across all visits, providers, and departments.
- Monitor Epic system changes that may affect PBB rule setup and engage stakeholders to evaluate the impact.
- Test new clinic builds before go-live, including end-to-end revenue cycle testing.
- Serve as escalation contact for PBB issues that may indicate setup problems or compliance gaps.
- Work closely with Credentialing and Enrollment teams to validate the accuracy of CMS PECOS enrollment for all hospital-based clinics, ensuring proper ownership, location details, and taxonomy alignment.
- Coordinate PECOS changes for new sites, relocations, closures, and mobile units.
- Maintain a master registry of all facility locations, including PBB status, addresses, CCNs, NPIs, and Epic location IDs.
- Ensure consistency across PECOS, NPPES, Epic, and payer credentialing databases to prevent billing errors and ensure compliance.
- Serve as the lead advisor for provider-based billing to leadership and key committees.
- Develop and maintain standards for policies, documentation requirements, Epic configurations, and compliance monitoring for adding, modifying, and assessing provider-based billing locations.
- Develop and deliver training about provider-based billing requirements and impact across operational, clinical, finance, and revenue cycle teams.
- Present risks, trends, and revenue opportunities to leadership.
- Coordinate cross-functional efforts with Compliance, Finance, Ambulatory, Legal, IT, and Revenue Cycle to ensure consistent and compliant provider-based billing practices.
Requirements
- Bachelor’s degree in healthcare administration, business, finance, or related field, or equivalent experience in a field related to compliance with provider-based requirements and billing.
- Minimum 5 years of experience in revenue cycle, reimbursement, or compliance within a healthcare environment
- Demonstrated experience interpreting and implementing federal regulations
- Experience conducting root cause analysis and performance improvement activities
- Experience conducting audits of revenue cycle workflows and billing system build to ensure compliance with regulations
- Strong analytical skills, including financial analysis, variance investigation, and data interpretation.
- Experience working with Epic.
- Experience with Microsoft Word, Excel, PowerPoint, Teams
- Exceptional written and verbal communication skills.
- Ability to translate complex rules into practical workflows.
- Strong critical thinking and problem-solving abilities.
- Comfort leading cross-functional initiatives with diverse teams.
- Proactive, self-directed, and highly organized.
Nice to Have
- Licensure/Certification
- Epic Certification in PB/HB, Prelude, Cadence, or Resolute.
Additional Information
- Keep abreast of changes in federal regulations applicable to provider-based billing
- Initiate first steps to resolve compliance issues and keeps management informed of progress or obstacles.
- Independently discover compliance risks, notify revenue cycle leadership, and develop a plan of action to resolve.
- Manage relationships with internal stakeholders inside and outside the organization, including Palmetto (Medicare Administrator), Ensemble, Legal, Compliance, Information Technology, Ambulatory, and Finance.
- Analyze and interpret complex data to identify trends and patterns.
- Periods of high stress and fluctuating workloads may occur.
- General office environment.
- Required to car travel to off-site locations, occasionally in adverse weather conditions.
- May have periods of constant interruptions.
- Climbing
- Work Position: Sitting, Walking, Standing
- Manual dexterity (eye/hand coordination), Repetitive arm/hand movements, Finger Dexterity
- Mental/Sensory – Emotional Mental / Sensory: Strong Recall, Reasoning, Problem Solving, Hearing, Speak Clearly, Write Legibly, Reading, Logical Thinking
- Emotional: Fast-paced environment, Able to Handle Multiple Priorities, Able to Adapt to Frequent Change
