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

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

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.

Preferred Qualifications

• 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 frameworks (Medicare/Medicaid managed care environments) preferred
• Experience in hospital billing, facility claims auditing, payment integrity, or revenue integrity, including itemized bill review preferred
• People management or team lead experience (direct or matrix) preferred
• Working knowledge of hospital billing and reimbursement concepts across inpatient/outpatient settings preferred
• Experience interpreting and applying payment policy, audit standards, and provider contract terms preferred
• Strong documentation, analytical, and decision-making skills; ability to produce defensible audit findings preferred

Job Level: Manager

Workshift: 1st Shift (United States of America)

Job Family: BSP > Program/Project