Quality Assurance & Compliance Manager

📋 Description

• • Nira Medical Inc. is at the forefront of advancing neurological care, operating as a national partnership of physician-led, patient-centered independent practices. Our core mission is to empower clinicians by providing access to life-changing treatments, thereby enabling them to deliver the best possible patient outcomes. Founded by neurologists who intimately understand the unique challenges within this specialized field, Nira Medical offers robust support to practices through cutting-edge technology, opportunities for clinical research, and a collaborative, comprehensive care network dedicated to elevating the standard of neurological care. As we embark on a significant phase of growth, our strategic focus is on scaling our teams, expanding our services, and significantly enhancing the patient and operational experience, ensuring peak readiness across all facets of our organization.
• • This pivotal role of Quality Assurance & Compliance Manager is designed to spearhead the design, meticulous implementation, and continuous execution of a robust enterprise-wide quality program. The primary objective is to guarantee unparalleled billing accuracy, stringent regulatory compliance, and unwavering revenue integrity across all Nira Medical practice locations. This position is instrumental in embedding structured quality controls deeply within our operational workflows. By proactively mitigating risks and fortifying our audit readiness, this role will establish and maintain a best-in-class Revenue Integrity Quality Management Program that underpins Nira’s multi-site neurology platform.
• • The Quality Assurance & Compliance Manager will be entrusted with the critical responsibilities of developing sophisticated, structured audit protocols that go beyond surface-level checks. You will oversee comprehensive compliance inspection frameworks, ensuring adherence to the highest industry standards. A key function will be the rigorous enforcement of established billing standards, leaving no room for ambiguity or deviation. Furthermore, you will manage and refine the corrective action processes, transforming identified issues into opportunities for systemic improvement. A significant part of this role involves advancing continuous quality improvement initiatives, fostering a culture where excellence is the norm. You will be the guardian of interface and claim integrity, ensuring that all data flows accurately and all claims are submitted correctly. Crucially, you will ensure that our Revenue Cycle Management (RCM) operations remain in strict compliance with all relevant federal and commercial regulations, including CMS regulations, Medicare Local Coverage Determinations (LCD) and National Coverage Determinations (NCD) policies, Commercial payer requirements, National Correct Coding Initiative (NCCI) edit standards, and our own stringent Internal billing governance protocols.
• • This is a fundamentally prevention-oriented leadership role, deeply focused on systematic risk reduction and instilling a culture of unwavering regulatory discipline. Your leadership will be crucial in shaping how we approach quality and compliance.
• • Enterprise Quality Program Leadership: You will be responsible for designing and implementing a comprehensive Quality Assurance/Quality Control (QA/QC) framework that spans all service lines and practice locations. This includes establishing formal, standardized audit standards and detailed inspection protocols. You will meticulously define quality control checkpoints at critical junctures within our revenue cycle workflows. Developing structured sampling methodologies and a risk-based approach to audit prioritization will be key to ensuring our efforts are focused and effective. Furthermore, you will lead quality validation efforts during the critical phases of new service implementation, practice onboarding, and significant system transitions, ensuring quality is built-in from the start.
• • Audit Execution & Compliance Oversight: You will conduct and oversee structured audits covering a wide array of crucial areas, including CPT/HCPCS coding accuracy, modifier integrity, diagnosis alignment with services rendered, medical necessity compliance, drug billing and unit accuracy, and pre-release claim validation. A significant part of your role will involve identifying systemic risk patterns by analyzing denial and scrub trends, providing actionable insights. You will be responsible for issuing formal findings based on audit results and managing the entire lifecycle of corrective and preventive action plans. Continuous monitoring of remediation efforts and validation of sustained improvement will be essential to ensure long-term success.
• • Billing Governance & Policy Control: You will develop and maintain a centralized billing guide governance system, complete with formal version control to ensure all stakeholders are working from the most current and accurate information. A critical task will be to monitor and integrate all relevant updates from CMS, revisions to MAC LCD/NCD policies, and changes in commercial payer policies into our operational framework. You will establish robust documentation control standards to guarantee audit defensibility and ensure consistent alignment of billing standards across all Nira Medical sites, promoting uniformity and reducing errors.
• • Regulatory & Audit Readiness: You will maintain meticulously structured audit documentation, detailed inspection logs, and comprehensive compliance reports. Ensuring readiness for various external audits, including Medicare audits, Recovery Audit Contractor (RAC) reviews, and commercial payer investigations, will be a primary focus. You will develop formal audit response frameworks and standardized documentation protocols to streamline these processes. Conducting thorough risk assessments to evaluate compliance exposure across all service lines will help us proactively address potential vulnerabilities. Finally, you will provide essential monthly and quarterly quality reporting to Revenue Cycle leadership, highlighting key metrics, identified risks, and opportunities for revenue protection and risk mitigation.