This position is primarily responsible for providing advice, support and monitoring with respect to Billing compliance, CPT Coding and Product Offering; for managing the Reimbursement IR process and for managing the compliance diligence process for potential acquisitions. This position is also responsible for representing the Company with industry groups and with the government in matters related to billing, product offering and CPT coding 

• CPT Coding  
  
  
  
  • This position is responsible for managing the manner in which the Company assigns CPT codes to tests.  This includes convening medical, scientific and legal support to choose codes in a sometimes murky area.   It includes interacting with government and industry groups regarding matters that will affect the Company in this area and working with billing and others to ensure that CPT coding is appropriately implemented, including any required changes.  The position also oversees a group of coders who assign CPT codes to various tests.  
  
  
  
  


• Product Offering   
  
  
  
  • This position is responsible for the compliance controls regarding test offerings, including panels and profiles.  Determining the appropriate product offering requires consideration of regulatory guidance as well as medical and technical matters.  This is a crucial functions, as it directly impacts reimbursement and creates enforcement risk if not handled appropriately.  This position is responsible for the majority of the controls that arose from the large recoveries against laboratories in the 90s, and which remain a high-risk area today. 
  
  
  
  


• Billing Compliance  
  
  
  
  • This position is responsible for providing billing Compliance guidance to Quest Diagnostics’ Business Units, Revenue Services and other departments regarding their compliance with Medicare, Medicaid, and other third party billing requirements and interfacing with Government Agencies and contractors, including the Centers for Medicare and Medicaid Services (CMS), State Medicaid Agencies, Medicare carriers, Medicaid fiscal agents, and other third party payors in the interests of Quest Diagnostics as it relates to payment issues, lobbying efforts or investigations by these agencies. 
  
  
  
  


• This position also communicates pending regulatory changes and legislation to Senior Management and assists in the company’s implementation planning for those changes as needed.  The position and its reports interface with ACLA as the Company representative on billing, coding and product offering matters.  The position works with Quest Diagnostics’ legal counsel and Quest Diagnostics’ outside counsel on billing-related litigation issues and billing-related governmental investigations. 


• Reimbursement Incident Reports process   
  
  
  
  • This includes overseeing the investigation of any suspected overpayment and the calculation of refunds and managing a large number (over 400) investigations a year.  The function is responsible for meeting the particular time requirements imposed by the federal law for making refunds to federal programs.  The group also analyzes the refunds to determine any trends or system weaknesses, and works with billing and other functions to implement fixes. 
  
  
  
  


• Provides guidance to Quest Diagnostics’ Business Units, Revenue Services, and other departments regarding their compliance with Medicare, Medicaid, and other third party billing requirements. 


• Oversees the Product Offering function and is responsible for ensuring compliance with applicable principles and guidelines.  This includes interacting with various SMT members and their reports regarding new test offerings and helping ensure the efficient operation of the Medical Compliance review committee.  


• Oversees the CPT Coding function and is responsible for appropriate assignment of CPT codes and driving required changes. 


• Provides oversight of the Reimbursement Investigation process including determining and implementing corrections and improvements and supervision of the Director, Compliance Reimbursement/audit defense. 


• Provides oversight of defense of government billing audits. 


• Assists the Business Units and Revenue Services department in resolving escalated coverage, payment and administrative issues directly with Medicare carriers and Medicaid fiscal agents. 


• Remains abreast of Medicare and Medicaid legislative and regulatory changes that impact coverage, payment and administrative policy; helps drive organizational response accordingly. 


• Facilitates advanced escalation of chronic payment and administrative issues through the correct channels of Government Agencies, as appropriate, including the Regional and Central Offices of CMS, State Medicaid Agencies and State Health Departments, and other third party issues as they relate to Quest Diagnostics ability to comply with regulations. 


• Assists in providing early notice to Quest Diagnostics’ Senior Management and impacted areas within the company regarding pending regulatory changes and legislation, and assist in the company’s implementation planning as needed. 


• Proactively advocates Medicare coverage, payment and administrative policy improvements with CMS, in conjunction with the Director of Government Affairs, both independently and via ACLA. 


• Proactively advocates Medicaid coverage, payment and administrative policy improvements with State Medicaid Agencies, in conjunction with the Director of Government Affairs, both independently and via ACLA. 


• Continues to Develop and maintain working relationships with key individuals within Government Agencies, their contractors and other industry constituents. 


• Oversees the compliance portion of due diligence activities. 


• Regarding billing compliance, CPT coding and product offering, if this function is not carried out, or is not carried out well, the company may incur significant legal and financial risk.  At the extreme, incorrect decisions or improper actions could result in the criminal and /or civil charges against individuals and the company; monetary penalties and prison sentences if found fraudulent. Exclusion from the Medicare and Medicaid programs is possible penalty, and could have extreme implication on the entire company and its reputation. More likely impact would be extensive loss of time and effort in research of current litigation, as well as refunding payments to Government payors, possible government penalties/fines, negative publicity to the company, as well as lost opportunity to collect Medicare and Medicaid revenue.   


• Regarding Product Offering, this area led to industry-wide settlements in the past, and remains an area of focus for enforcement.  A strong product offering function is also crucial the Company’s relationship with private payers.   


• With respect to CPT coding, the assignment of CPT codes is critical to the Company’s ability to gain reimbursement for out testing services.  Assigning a code often involves specialized research and high-level judgment to determine the appropriate code.  Assigning an incorrect code could lead to inadequate reimbursement and/or potential liability to government and other health plans. 


• With respect to the diligence process for proposed acquisitions, failure to perform diligence adequately may lead to purchasing an entity that would carry significant liability including potential false claims act exposure, and/or will be unprofitable when compliance issues are addressed. 


• Principal Decisions: 
  
  
  
  • Providing accurate compliance advice regarding billing requirements. 
  
  
  • Determining when refunds are owed and calculation of the amount 
  
  
  • Determining the appropriate defense to government billing audits 
  
  
  • Identifying and facilitating any corrective actions or improvements with respect to matters identified through the Reimbursement IR process, audit defense or compliance billing advice. 
  
  
  • Determining which situations warrant involvement of in-house legal counsel or outside counsel, as appropriate, and interfacing with counsel. 
  
  
  • Facilitating decisions regarding which coverage, payment and administrative policy issues are material to the Company, and communicating such priorities internally and externally. 
  
  
  • Determining appropriate escalation strategy for chronic coverage, payment and administrative policy issues within Government Agencies and their contractors. 
  
  
  • Determining whom to communicate with internally regarding legislative, regulatory or company policy changes. 
  
  
  • Determining appropriate CPT coding 
  
  
  • Identifying and communicating significant compliance issues in the diligence process 
  
  
  • Assessing the various regulatory guidance and risk factors and recommending the appropriate course of action with respect to coding, product offering and billing compliance. 
  
  
  
  


• People Leader Responsiblities:
  
  
  
  • Direct: 
    
    
    
    • 3 Compliance Directors (grade 51) 
    
    
    • 1 Product Offering Manager (grade 50)   
    
    
    
    
  
  
  • Indirect: 
    
    
    
    • 2 Senior Medical Coding Specialist (grade 49) 
    
    
    • 2 Medical Coding Specialist II (grade 48) 
    
    
    • 4 Senior Compliance Analysts (grade 49) 
    
    
    
    
  
  
  
  

QUALIFICATIONS

Required Work Experience:  

At least 7 years experience, preferably in the healthcare environment doing business with Medicare and Medicaid as a clinical laboratory, or similar third party payor relationship. 

Preferred Work Experience:  

N/A

Physical and Mental Requirements:  

• Perform job duties with frequent interruptions or distractions 


• Ability to sit or stand for long periods of time 

Knowledge:  

Thorough understanding of health care coverage, payment and administrative policy, and its business impact on billing, operations and financials. 

Skills:  

• Adjust priorities quickly as circumstances dictate.  


• Ability to interact professionally with colleagues and/or customers for different purposes in different contexts. 


• Maintain composure under pressure  


• Performs a variety of duties, often changing from one task to another  


• Ability to comprehend and follow verbal or written instructions 


• Using effective verbal communication  


• Using effective written communication  


• Concentrate on tasks  


• Ability to making decisions 


• Excellent negotiation, communications and networking skills, including the ability to communicate complex issues clearly and concisely to internal and external constituencies. 


• Proven leadership and management abilities 


• Proven ability to work in a fast-past, rapidly changing environment 

EDUCATION
Master’s Degree(Required)

LICENSECERTIFICATIONS

Equal Opportunity Employer: Race/Color/Sex/Sexual Orientation/Gender Identity/Religion/National Origin/Disability/Vets