Quality Assurance & Compliance Manager

Quality Assurance & Compliance Manager

Overview

Nira Medical is a national partnership of physician-led, patient-centered independent practices committed to driving the future of neurological care. Nira’s mission is to enable clinicians to provide access to life-changing treatments so you can provide the best possible patient outcomes. Founded by neurologists who understand the unique challenges of the field, Nira Medical supports practices with cutting-edge technology, clinical research opportunities, and a collaborative and comprehensive care network dedicated to advancing the standard of care. As we enter the next phase of growth, our focus is on scaling our teams, services, and elevating the customer’s experience. readiness. This Is Where You Come In The Quality Assurance & Compliance Manager will help lead the design, implementation, and ongoing execution of this enterprise quality program, ensuring billing accuracy, regulatory compliance, and revenue integrity across all practice locations. This role is responsible for embedding structured quality controls into operational workflows to proactively mitigate risk and strengthen audit readiness. The Quality Assurance & Compliance Manager will establish and maintain a best-in-class Revenue Integrity Quality Management Program across Nira’s multi-site neurology platform. This position is responsible for:

• Developing structured audit protocols
• Overseeing compliance inspection frameworks
• Enforcing billing standards
• Managing corrective action processes
• Advancing continuous quality improvement initiatives
• Safeguarding interface and claim integrity
• Ensuring RCM remains compliant with CMS regulations, MAC LCD/NCD policies, Commercial payer requirements, NCCI edit standards, and Internal billing governance protocols

Here’s What You’ll Be Doing: This is a prevention-oriented leadership role focused on systematic risk reduction and regulatory discipline. Enterprise Quality Program Leadership

• Design and implement a comprehensive QA/QC framework across all service lines and practice locations.
• Establish formal audit standards and inspection protocols.
• Define quality control checkpoints within revenue cycle workflows.
• Develop structured sampling methodologies and risk-based audit prioritization.
• Lead quality validation efforts during new service implementation, onboarding, and system transitions.

Audit Execution & Compliance Oversight

• Conduct and oversee structured audits of:
• CPT/HCPCS coding accuracy
• Modifier integrity
• Diagnosis alignment
• Medical necessity compliance
• Drug billing and unit accuracy
• Pre-release claim validation
• Identify systemic risk patterns through denial and scrub trend analysis.
• Issue formal findings and manage corrective and preventive action plans.
• Monitor remediation efforts and validate sustained improvement.

Billing Governance & Policy Control

• Develop and maintain centralized billing guide governance with formal version control.
• Monitor and integrate CMS updates, MAC LCD/NCD revisions, and commercial payer policy changes.
• Establish documentation control standards to ensure audit defensibility.
• Align billing standards consistently across all sites.

Regulatory & Audit Readiness

• Maintain structured audit documentation, inspection logs, and compliance reports.
• Ensure readiness for Medicare audits, RAC reviews, and commercial payer investigations.
• Develop formal audit response frameworks and documentation protocols.
• Conduct risk assessments to evaluate compliance exposure across service lines.
• Provide monthly and quarterly quality reporting to Revenue Cycle leadership.
• Identify measurable opportunities for revenue protection and risk mitigation.
• Ability to travel up to 25% as needed to conduct site level audits, compliance reviews, and workflow validations across multi-site operations.

What We’re Looking For: Required

• 7+ years of progressive experience in healthcare revenue integrity, auditing, compliance, or quality management.
• Demonstrated experience designing and implementing structured QA/QC or revenue integrity programs in multi-site healthcare environments.
• Advanced knowledge of CMS billing regulations, MAC LCD/NCD policies, Commercial payer reimbursement structures, CPT/HCPCS coding standards, Modifier compliance logic, and FDA Indications & Medical Necessity requirements
• Experience in managing audit documentation, corrective action workflows, and compliance governance.
• Strong analytical capability with the ability to interpret complex billing data and regulatory guidance.
• Executive-level written and verbal communication skills.

Preferred

• CPC, CPMA, RHIA, RHIT, or equivalent certification.
• Experience within neurology, infusion therapy, specialty pharmaceuticals, or other high-complexity service lines.
• Experience in MSO or multi-practice healthcare platforms.

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