Description

Job Summary

Reporting to the Manager of Billing Compliance, this position supports the Corporate Compliance Program by conducting routine audits and investigations related to coding, billing, documentation, and operational quality assurance processes that impact payer reimbursement for medical services. The Senior Auditor applies corporate policy, payer contract requirements, and federal and state regulations to identify, communicate, and resolve risks affecting claim payment, in partnership with administrative and clinical leadership.

 The Senior Auditor ensures execution of the Billing Compliance Audit Work Plan and conducts internal compliance investigations in response to billing concerns. This role supports internal and external (government and payer) audit activities, including Medicare and Medicaid, by ensuring audit readiness, validating documentation, and assisting with audit responses. 

 The auditor maintains comprehensive documentation of all audits and investigations, including interviews, claim audits, control assessments, root cause analysis, corrective action planning, and overpayment calculations, as warranted. Responsibilities also include leveraging Microsoft Excel for data analysis, data mining, and reimbursement calculations, and Microsoft Word for detailed audit reporting, investigation summaries, and compliance documentation.

Responsibilities and Essential Functions 

1. Conduct comprehensive retrospective and prospective coding, billing, and documentation audits across the medical group and all system facilities. Analyze source documents (including progress notes, operative reports, pathology reports, etc.) and associated billing documentation (such as encounter forms, EOBs, Epic billing data and related records) to ensure coding and billing accuracy. Audits ICD-10-CM, CPT/HCPCS or ICD-10-PCS codes for appropriateness compared to medical record documentation, applying appropriate corporate policies, state and federal regulations, coding rules, commercial payer guidelines, and Medicare/Medicaid standards (e.g., NCDs, LCDs, Medicare Manuals, and DRG/APC/RBRVS/other relevant Prospective Payment System billing rules). (20%)
2. Lead and support internal Compliance investigations in response to billing concerns and external inquiries, including high-risk scenarios requiring timely, thorough, and confidential review. (20%)
3. Identify trends, patterns, and potential risks in coding and billing practices; communicates findings and escalates issues for further investigation and corrective action. (10%)
4. Maintain comprehensive documentation of audit and investigation activities, including interviews, claim reviews, control assessments, root cause analysis, and corrective action plans, ensuring audit readiness and regulatory compliance. (10%)
5. Calculate reimbursement impact, statistical error rates, and overpayment estimates using Microsoft Excel, incorporating data mining, validation techniques, and extrapolation methodologies as needed. (10%)
6. Support internal and external (government and payer) audit activities by preparing documentation, validating data, and assisting in audit responses. Manages and executes multiple concurrent audits while maintaining accuracy, timeliness, and compliance standards. (10%)
7. Facilitates communication of audit and investigational results across clinical, operational, and compliance teams to support resolution and process improvement. (5%)
8. Maintain current knowledge of coding, billing, and regulatory requirements, including annual updates to ICD-10-CM/PCS and CPT/HCPCS, and Medicare regulatory updates. Maintain required certification(s). (5%)
9. Contribute to special projects and initiatives supporting compliance and audit across the system. (10%)

Requirements

Education: Bachelor's degree, required

Certification: RHIA or RHIT or Nurse with coding certification (CCS, CPC), required

Experience: 3+ years with focus on regulatory billing compliance and facility/professional revenue cycle experience.

• Extensive experience conducting compliance audits, and analyzing Revenue Cycle functions, including ICD-10, CPT, and HCPCS coding accuracy. Medicare Policy requirements, and the operational workflows affecting hospital and physician billing.
• EPIC experience, strongly preferred

Knowledge, Skills and Abilities (KSAs)

• Extensive experience conducting compliance audits, and analyzing Revenue Cycle functions, including ICD-10, CPT, and HCPCS coding accuracy. Medicare Policy requirements, and the operational workflows affecting hospital and physician billing.
• Skilled in medical coding, compliance research, and investigative analysis, with the ability to apply regulatory and coding updates to audit findings and corrective action initiatives.
• Proficient in interpreting a variety of clinical documents, CMS policies, third-party payer guidelines, and government regulations, ensuring audits are accurate, thorough, and aligned with compliance requirements.
• Strong communication skills, with the ability to convey complex coding and compliance information effectively to non-coding staff across clinical, operational, and administrative teams. 
• Ability to manage and execute multiple concurrent audits while maintaining accuracy, timeliness, and compliance standards.
• Advanced Microsoft Excel (data analysis, pivot tables, VLOOKUP/XLOOKUP, data validation, reporting)
• Proficient in Microsoft Word (audit reports, documentation, formatting, templates)