Manager, Hospital Bill Audit & Itemized Bill Review (Program Integrity)

Requirements

• Bachelor's degree in nursing, or related field preferred
• Certifications: CHC, CPC, RHIA/RHIT (any relevant).
• Experience with payment integrity platforms, claims editing logic, or audit workflow tools preferred
• Experience supporting appeal defense and provider dispute resolution preferred
• Familiarity with federal and state program integrity framework

Additional Information

Anticipated End Date: 2026-06-19 Position Title: Manager, Hospital Bill Audit & Itemized Bill Review (Program Integrity) Job Description: Location: Norfolk VA, Mason OH, Indianapolis IN, Louisville KY, Atlanta GA, Miami FL, Grand Prairie TX, Overland Park KS Hours: Standard Working hours Travel: This role requires associates to be in-office 3 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law. Position Overview: The Manager of Hospital Bill Audit & Itemized Bill Review leads the strategy, execution, and continuous improvement of hospital claim audits and itemized bill review functions within the Program Integrity organization. This role manages a team responsible for identifying billing errors, enforcing payment policy and contractual requirements, reducing inappropriate spend, and supporting pre- and post-payment controls through clinically and financially sound review of itemized bills (UB-04 claim forms and supporting documentation such as itemized statements and medical records, as applicable). How You Will Make an Impact: Lead daily operations for hospital bill audits and itemized bill reviews, ensuring accuracy, productivity, and compliance with internal policies and regulatory standards. Manage, coach, and develop a team of auditors/reviewers (and potentially vendor resources), including hiring, onboarding, training, performance management, and career development. Establish and maintain standard operating procedures (SOPs), quality controls, and escalation pathways for complex audits and high-risk billing patterns. Oversee workflow intake, triage, prioritization, and turnaround time commitments for audits and bill reviews (e.g., IP, OP, ER, observation, ambulatory surgery, facility ancillary, high-dollar claims). Oversee itemized bill review for: revenue codes, HCPCS/CPT mapping, units/quantity validation, charge/cost reasonableness, packaging/bundling rules, NCCI edits (as applicable to setting), and duplicate or unbundled charges. Ensure appropriate application of: payer payment policies, CMS guidelines (where applicable), state/federal regulations, and provider contract terms (including reimbursement methodologies and carve-outs). Direct investigation and documentation of suspected waste, abuse, or fraud indicators and coordinate referrals to SIU/Compliance/Legal per policy. Support both pre-payment and post-payment audit strategies, including clinical documentation requests when required to substantiate billed services. Partner with analytics to identify outliers, emerging billing risks, and provider/claim targets using utilization trends, charge patterns, and audit findings. Translate audit results into actionable initiatives (edit development, provider education, contract language recommendations, and process improvements). Monitor recoveries, avoidance, overturn rates, and appeal outcomes to refine audit logic and improve defensibility. Own quality assurance (QA) program for audit determinations, ensuring consistent rationale, complete workpapers, and strong evidence trails. Oversee preparation of audit summaries, demand letters support, and appeal/negotiation packages; collaborate with Claims, Provider Relations, and Appeals teams as needed. Provide clear, professional communication to internal stakeholders and, when appropriate, support provider education on common billing issues. Ensure audits and bill reviews are performed in alignment with regulatory requirements, accreditation standards (as applicable), privacy/security rules (HIPAA), and record retention guidelines. Maintain audit-ready documentation practices and support internal/external audits of Program Integrity activities. Manage vendor oversight if external audit firms are used: scope, performance metrics, validation, and invoicing. Required Qualifications: Requires a BA/BS and minimum of 5 years experience in project/program management, process reengineering, organizational design, and/or implementation; or any combination of education and experience, which would provide an equivalent background.

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