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* This is a hybrid position to be located in WI with travel required. *
JOB SUMMARY
The Coding and Billing Compliance Analyst plays a critical role in safeguarding the accuracy, integrity, and regulatory compliance of coding and billing operations across all service lines. This position supports the organization’s revenue cycle and compliance initiatives by conducting detailed coding and billing reviews, identifying areas of risk, and contributing to the development of corrective action plans and educational programs. The analyst ensures adherence to federal and state billing regulations, including Medicaid/Medicare guidelines, HRSA program requirements, and Office of Inspector General (OIG) guidance specific to Federally Qualified Health Centers (FQHCs). The Analyst collaborates with providers, billing teams, compliance officers, and revenue cycle leadership, to improve clinical documentation, optimize reimbursement, and maintain full compliance with all applicable standards and payer requirements.
ESSENTIAL JOB FUNCTIONS
- Reviews provider documentation, medical records, and associated charges to ensure correct assignment of ICD-10, CPT, HCPCS codes, and modifiers according to payer, CMS, HRSA, and FQHC-specific guidelines.
- Conducts regular audits of coding, billing, and claims to ensure accuracy, completeness, and compliance with CPT, CDT, HCPCS, ICD-10, and payer-specific guidelines.
- Monitors claims submissions, pre-bill edits, denials, and payor feedback and identify coding and billing errors or trends and recommend corrective actions and coordinate follow-up audits as needed.
- Assists in developing, updating, and maintaining coding and billing compliance policies, procedures, training materials as guidelines or payor rules change.
- Collaborates proactively with providers, clinical teams, and billing staff to ensure accurate documentation, compliant coding practices, and adherence to Medicaid coverage and reimbursement requirements.
- Analyzes denied or underpaid claims to identify root causes, including coding errors, documentation gaps, or payer-specific policy issues, and collaborate with interdepartmental teams to implement targeted process improvements that strengthen billing compliance and optimize revenue integrity.
- Monitors and interprets payer updates, coding changes, and reimbursement policy revisions from CMS, HRSA, Medicaid, and commercial payers; evaluates their impact on FQHC operations and communicates relevant updates, guidance, and action steps to affected departments to ensure compliance and optimized reimbursement.
- Monitors coding practices for compliance with FQHC Prospective Payment System (PPS) and encounter-based billing guidelines.
- Performs charge reviews comparing itemized bills to medical record documents to ensure appropriate charges.
- Conducts regular staff training sessions for providers, billers, and clinical staff on documentation, coding updates, and compliance best practices.
- Prepares audit reports and presents findings to leadership and compliance officer.
- Maintains strict adherence to scheduled work hours with regular and reliable attendance.
- Performs other duties as assigned.
EDUCATION AND EXPERIENCE
- Minimum of 3-5 years of experience in medical billing, coding, and/or compliance within a healthcare setting is required; FQHC experience preferred.
- Proficiency with EHR and practice management systems (e.g., Epic Systems, NextGen Healthcare, eClinicalWorks).
- Associate’s or degree in Health Information Management, Healthcare Administration, or related field preferred.
CERTIFICATIONS / LICENSES
- Certified Professional Coder (CPC), awarded by American Academy Professional Coders (AAPC) required.
- Additional credentials such as Certified Compliance Professional (CCP) preferred.
- Valid Wisconsin Driver’s License required with an acceptable motor vehicle record (MVR), per FHC guidelines.
Equal Employment Opportunity
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