Compliance Auditor

Position Highlights:

• Compliance Auditors conduct Compliance Department audits to determine organizational integrity of billing for professional (physician) services and/or hospital (technical) services, including detection and correction of documentation, coding, and billing errors. The Compliance Auditor evaluates the adequacy and effectiveness of controls designed to ensure that processes and practices lead to appropriate execution of regulatory requirements and guidelines related to professional or hospital documentation, coding and billing, and federal and state regulations and guidelines.
• The Compliance Auditor communicates audit results to physicians, physician leadership, senior management, management, and staff and provides physician and coder education.
• The Compliance Auditor will act as a liaison with assigned faculty members, developing relationships and functioning as a resource to all providers and their staffs and will serve as an institutional subject matter expert and authoritative resource.

The Ideal Candidate Will Have The:

• Understanding of institutional risks and appropriate judgment to use a risk-based approach in planning and executing duties.
• Ability to work in both independent contributor and team roles (both as a team leader and team member)
• Ability to communicate complex and potentially sensitive issues to all levels of management including senior leadership.

Responsibilities:

• Plans and performs scheduled and unscheduled professional or hospital compliance department audits, including accuracy and adequacy of documentation and coding related to physician or hospital (inpatient and outpatient) billing and/or medical necessity reviews.
• Evaluates the appropriateness of services and procedures billed based on supporting documentation.
• Prepares written reports of audit findings and recommendations and presents to appropriate stakeholders; evaluates the adequacy of management corrective action to improve deficiencies; maintains audit records.
• Conducts risk assessments to define audit priorities by evaluating previous audit findings, management priorities, coding utilization patterns, national normative data, CMS and CCI initiatives, OIG work plans and advisories and healthcare industry best practices.
• Develops compliance training content and provides one-on-one and group training to faculty physicians, advanced practitioners, billing and coding staff and others.
• Conducts compliance orientation training for new providers.
• Researches, abstracts and communicates federal, state and payer documentation, billing and coding rules and regulations. Serves as institutional subject matter expert and authoritative resource in these areas.

Credentials and Qualifications:

• Bachelor's degree in Health Information Management, Business or related field.
• Three (3) years of experience in physician and/or hospital technical coding/auditing, medical necessity reviews, or related work.
  • **In lieu of a bachelor’s degree, HS Diploma/GED and seven (7) years of relevant experience will be considered.
• Must possess an AAPC or AHIMA coding certification (CPC, CCS, CCS-P, COC, or RHIA, etc.).
• Extensive knowledge of evaluation and management and/or hospital facility fee coding and auditing.
• Knowledge of Medicare and Medicaid documentation and coding rules and guidelines.
• Ability to interpret and apply documentation and coding rules and regulations and to interpret medical record progress notes, handwritten and electronic chart entries, provider orders and other related documentation.

Preferred:

• Professional and/or hospital services auditing experience in an Academic Medical Center.
• Prior experience working in a Corporate Compliance environment.
• Prior experience working in a Cancer Hospital.
• Prior experience working in a Revenue Cycle Operations role.
• Knowledge of Soarian and/or Soarian PRM applications.
• Knowledge of Cerner Powerchart applications.