IBHS Compliance and Billing Officer

Position Summary

Reaching Beyond Limits is seeking an experienced IBHS Compliance and Billing Officer to oversee regulatory compliance, quality assurance, clinical documentation, billing operations, and revenue-cycle processes for its Pennsylvania Intensive Behavioral Health Services program.

The ideal candidate will have direct experience with Pennsylvania Medical Assistance, HealthChoices managed care organizations, behavioral-health billing, service authorizations, claim submission, denial resolution, and regulatory compliance. This position will help establish reliable billing and compliance systems while ensuring that services are properly authorized, documented, billed, and reimbursed.

Essential Duties and Responsibilities

IBHS Compliance and Quality Assurance

• Monitor agency compliance with 55 Pa. Code Chapter 5240 and other applicable Pennsylvania IBHS requirements.
• Maintain current knowledge of requirements issued by the Pennsylvania Department of Human Services, OMHSAS, Medical Assistance, HealthChoices managed care organizations, and other applicable payers.
• Conduct routine and targeted audits of clinical, billing, authorization, personnel, and administrative records.
• Review clinical records for completeness, accuracy, timeliness, medical necessity, required signatures, and compliance with payer and regulatory requirements.
• Verify consistency among assessments, written orders, treatment plans, service authorizations, progress notes, data, and billed services.
• Identify documentation, regulatory, credentialing, authorization, and billing concerns and communicate findings to agency leadership.
• Develop, implement, and monitor corrective action plans.
• Track identified deficiencies and verify that corrective actions are completed within established timeframes.
• Prepare the agency for OMHSAS licensing reviews, managed care organization audits, credentialing reviews, and requests for records.
• Assist with responding to audit findings and developing plans of correction.
• Develop and update compliance policies, procedures, audit tools, monitoring systems, and documentation standards.
• Provide compliance and documentation training to clinical, billing, administrative, and leadership staff.
• Monitor incident-reporting procedures and ensure required reports are completed and submitted within applicable timeframes.
• Review staff credentials, licenses, clearances, exclusions, training requirements, supervision records, and personnel files for compliance.
• Monitor adherence to HIPAA, confidentiality requirements, client rights, ethical standards, and applicable state and federal regulations.
• Maintain a confidential process through which employees may report compliance concerns without retaliation.
• Investigate suspected documentation, billing, regulatory, ethical, privacy, or policy violations.
• Communicate significant compliance concerns to agency leadership and assist with repayment, self-disclosure, or external reporting when required and authorized.
• Prepare regular compliance reports identifying findings, trends, risks, corrective actions, and recommendations.

Billing and Revenue-Cycle Responsibilities

• Oversee the agency's billing and revenue-cycle processes for IBHS.
• Confirm that services are properly authorized, documented, coded, billed, and reimbursed.
• Review documentation before claim submission to verify medical necessity, provider eligibility, service authorization, correct procedure codes, modifiers, service locations, billing units, and required signatures.
• Reconcile scheduled, rendered, documented, authorized, and billed services.
• Monitor authorization approvals, authorized units, utilization, expiration dates, and requests for continued services.
• Prevent billing for services that are undocumented, insufficiently documented, unauthorized, outside the provider's credentials, or otherwise ineligible for reimbursement.
• Submit claims or oversee claim submission to Pennsylvania Medical Assistance, HealthChoices managed care organizations, and other applicable payers.
• Review electronic claim reports, remittance advice, payment information, denials, rejections, and recoupment notices.
• Investigate and resolve denied or rejected claims in a timely manner.
• Correct and resubmit eligible claims and coordinate voids, adjustments, and repayments when necessary.
• Identify recurring denial patterns and develop corrective procedures to address their causes.
• Monitor accounts receivable and follow up on unpaid, underpaid, or aging claims.
• Audit billing for duplicate claims, overlapping services, incorrect codes or modifiers, unsupported units, credentialing concerns, authorization discrepancies, and potential overpayments.
• Coordinate with clinical staff to resolve documentation and billing discrepancies.
• Develop written billing procedures, internal controls, workflows, and staff responsibilities.
• Train clinical and administrative staff regarding documentation-to-billing requirements.
• Maintain organized records supporting claims, payments, adjustments, voids, denials, appeals, and repayments.
• Produce regular reports addressing claims submitted, payments received, denial rates, accounts receivable, authorization utilization, and identified billing risks.
• Recommend improvements to the agency's electronic health record, scheduling, authorization, documentation, and billing workflows.

Preferred Qualifications

• Bachelor's degree in healthcare administration, behavioral health, social work, psychology, business administration, accounting, compliance, or a related field.
• Minimum of three years of healthcare or behavioral-health billing, revenue-cycle, compliance, auditing, or quality-assurance experience.
• Direct experience with Pennsylvania Medical Assistance or Medicaid billing.
• Knowledge of behavioral-health service authorizations, claim submission, remittance advice, denials, corrections, resubmissions, voids, and accounts receivable.
• Working knowledge of Pennsylvania IBHS regulations and documentation requirements.
• Experience reviewing clinical documentation for medical necessity and billing support.
• Knowledge of HIPAA, confidentiality, fraud, waste and abuse, exclusion screening, incident reporting, and healthcare compliance requirements.
• Ability to interpret regulations, contracts, payer guidance, and billing requirements and translate them into practical agency procedures.
• Strong analytical, organizational, written communication, training, and problem-solving skills.
• Ability to maintain confidentiality, professional objectivity, and sound judgment when handling sensitive information.
• Direct experience working for a Pennsylvania IBHS provider.
• Experience with HealthChoices behavioral-health managed care organizations.
• Experience preparing for OMHSAS licensing reviews and managed care audits.
• Experience managing the full behavioral-health revenue cycle.
• Experience with CentralReach or a comparable electronic health record and billing platform.
• Certification in Healthcare Compliance, medical billing, coding, revenue-cycle management, or a related area.
• Experience developing billing systems, compliance programs, staff training, internal controls, and corrective action plans.

Knowledge, Skills, and Competencies

• Pennsylvania IBHS regulatory knowledge
• Behavioral-health billing and revenue-cycle management
• Medical Assistance and managed care billing
• Clinical documentation auditing
• Service authorization monitoring
• Claims submission and denial resolution
• Accounts receivable monitoring
• Compliance investigations
• Licensing and audit preparation
• Corrective action planning
• Policy and procedure development
• Staff training
• Data analysis and reporting
• Confidentiality and ethical decision-making
• Strong attention to detail
• Effective communication across clinical, administrative, billing, and leadership teams

Required Clearances and Screenings

The selected candidate must obtain and maintain all clearances and screenings required for employment with a Pennsylvania child-serving behavioral-health organization, which may include:

• Pennsylvania State Police Criminal History Clearance
• Pennsylvania Child Abuse History Clearance
• FBI Criminal History Clearance
• Federal and state healthcare exclusion screenings
• Any additional background, credentialing, or payer-required screenings

Work Requirements

This position primarily involves office-based administrative work and may require prolonged computer use, participation in meetings, review of electronic and paper records, and occasional travel to agency service locations. The employee must be able to manage multiple deadlines, respond to audit or billing concerns promptly, and maintain confidentiality when handling protected health and employment information.

Equal Employment Opportunity

Reaching Beyond Limits, Inc. and all its entities provide equal employment opportunities to all employees and applicants and prohibit discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.

This policy applies to all employment terms and conditions, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.