Wilshire hires only the brightest and most experienced professionals in the healthcare revenue cycle management industry. Wilshire will take the time to get know you and your employment history. We will then place you in a role that will lead to a path of career success.

In close collaboration with the Chief Compliance Officer, designs and oversees the strategic direction and goal-setting for
Compliance Billing Integrity operations and ensure the s development of outcome programs to support the direction of the organization.

Oversees the direction and management of Compliance Billing Integrity operations for hospital billing integrity and physician
billing integrity programs, including strategic planning, process improvement, change management, and oversight of audit,
education and training; leads confidential and complex investigations of potential billing errors and billing fraud.

Compiles, analyzes and integrates data and metrics for continuous improvement of the Compliance Billing Integrity programs,
coordination and efficient performance of Compliance Billing Integrity initiatives, development and implementation of tools,
forms, and educational materials to improve organizational billing integrity performance.

Oversees Compliance preparedness for billing integrity regulatory scrutiny in accordance with laws, regulations, billing
manuals, documentation and coding rules, and principles of false claims and fraud, waste and abuse; directs operational
activities of the Compliance Billing Integrity program relating to compliance with federal and state laws and regulations for

accurate facility and professional billing.
Develops and oversees compliance billing integrity standards, policies, procedures and practices; oversees the direction,
implementation and sustainment of Compliance Billing Integrity programs and documentation that demonstrates an
organizational-wide billing integrity program.

Identifies and manages metrics and performance goals for the Compliance Billing Integrity team; sets metrics for each level of
staff and team performance; establishes criteria for reporting to support day-to-day program management; establishes and
maintains metrics to demonstrate progress towards goals and effectiveness of the Compliance Billing Integrity program;
works continuously to improve the Compliance Billing Integrity program.

Ensures the development, implementation, improvement and sustainability of comprehensive Compliance Billing Integrity
audit plans, including hospital fee audits, professional services audits, routine and focused audits, proactive and reactive
audits; develops and executes a comprehensive annual audit plan.

Manages and resolves response to government documentation, coding, and billing audits; responds to alleged violations of
documentation, coding and billing rules, regulations, policies and procedures.

Oversees the direction and management of partnerships with numerous entities and stakeholders, including Stanford Health
Care, Lucile Packard Children's Hospital Stanford, University Healthcare Alliance, Packard Children's Health Alliance,
ValleyCare Hospital, the School of Medicine, faculty physicians, Department Chairs and Division Chiefs; develops and
maintains reports for the various entities' senior leaders and Board of Directors.

Oversees the direction and management of Compliance Billing Integrity resources, including education, training, awareness,
guidance, learning aids, website and other resources.

Oversees and directs proactive Compliance Billing Integrity programs to detect and prevent compliance risks; assesses
organizational systems to determine gaps in compliance billing integrity and determines opportunities for remediation; leads
and manages efforts to identify potential compliance billing integrity issues and areas of compliance billing integrity
vulnerability and risk; evaluates and executes compliance billing integrity risk mitigation plans and corrective actions plans.

Obtains sufficient, competent and relevant regulatory documentation to afford a reasonable basis for analysis, judgment and
conclusions; stays current with applicable government rules and regulations; maintains current compliance billing integrity
resources and information.

• Works collaboratively with leadership to foster a culture of billing integrity throughout the organization

• Thirteen (13) years directly related work experience in the specialty area assigned

• Ability to maintain competence in and up-to-date knowledge of healthcare compliance requirements, practices and trends.
• Ability to maintain confidentiality of sensitive information.

Ability to model and demonstrate consistently high standards of professional ethics, integrity and trust Ability to perform
research and analysis of health care laws, regulations and policies as well as compliance issues.

• Ability to plan, organize, motivate, mentor, direct and evaluate the work of others.
• Ability to plan, organize, prioritize, work independently and meet deadlines.
• Ability to solve problems and identify solutions.

Ability to understand, interpret and apply complex federal and state hospital compliance laws, rules, regulations and
guidelines.

• Demonstrated ability to use judgment and make sound decisions.
• Knowledge of and ability to research laws, regulations and billing rules, including CMS manuals and Medi-Cal rules.

Knowledge of hospital/technical and professional services reimbursement systems (OPPS, IPPS, Professional fee, Medicare,
Medi-Cal and other appropriate payment systems).

• Knowledge of labor relations; economics; legislation affecting hospital administration, and compliance integrity programs.
• Knowledge of organization and functioning of hospitals, emergency departments and ambulatory care clinics.

Knowledge of principles and practices of organization, administration, fiscal and personnel management Knowledge of
revenue cycle and charge description master and identification of risks of and opportunities for charge capture.

• Knowledge of theories, principles and practices of strategic planning, program evaluation and improvement.

Wilshire is honored that you have taken the time to review/apply to our open position. We will now take the time to review your experience and be in touch with you soon.