Job Purpose:

The Compliance Auditor will conduct 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 and/or medical necessity of services billed. Audits consist of evaluation of the adequacy and accuracy of documentation in support of services billed, and compliance with other documentation and coding and billing standards.

Reporting to the Chief Compliance Officer, this position will communicate the audit results to physicians, physician leadership, senior leadership, management, and staff; provide physician and coder education; and make recommendations for corrective action to leadership, coders, billers and other appropriate staff.  The Compliance Auditor will act as a liaison with assigned team members, developing relationships and functioning as a resource to all providers and their staffs. He/she will serve as an institutional subject matter expert and authoritative resource on interpretation and application of documentation and coding rules and regulations, medical necessity of services delivered, and conduct enterprise risk assessments of potential and detected compliance deficiencies.

Essential Functions:

• Plans and performs scheduled and unscheduled professional 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; provides one-on-one and group training to ensure compliance with federal and state regulations and laws, CMS and other third party payer billing rules and internal documentation, coding and billing policies and procedures. Conduct compliance orientation training for new providers & Revenue Cycle team members in a one-on-one or group session.
• 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.
• Direct assigning of ICD-9 and ICD-10 codes by analyzing patient medical records

• Ensure documentation by providers conforms to legal and procedural requirements
• Consults with follow-up team prior to assigning claims to the appeals department for disputed / denied claims.
• Provides feedback/training for physicians and staff in with any coding insufficiencies
• Assist with research of denied claims
• Applies modifiers, checks CCI edits and assists with charge entry
• Maintain awareness of governmental regulations, protocols and third party requirements in reference to coding principles
• Maintain a working knowledge of EMR, the registration process and charge entry
• Ability to work effectively with providers and co-workers
• Regular attendance and punctuality.
• Contributes to team effort by accomplishing related results as needed.
• Ensures that all processing and reporting deadlines are consistently achieved.
• Perform any other functions as required by management.

Qualifications and Education Requirements

• Bachelor's degree in Health Information Management, Business or related field**In lieu of a Bachelor's Degree, HS Diploma/GED and five (5) additional years of relevant experience will be considered

• Must possess an AAPC or AHIMA coding certification (CPC, CCS, CCS-P, COC, or RHIA, etc.)

• Minimum three (3) years of experience in physician and/or hospital technical coding/auditing, medical necessity reviews, or related work.

• 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; ICD/CPT/HCPCS/DRG/APC documentation coding rules; charge capture and reimbursement methodologies; medical terminology; E/M rules, teaching physician guidelines, and/or medical necessity defense reviews; healthcare compliance audit methodology, principles and techniques; CMS manuals; professional and/or hospital services reimbursement and repayment; confidentiality standards.

• 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.

• Strong attention to detail, organizational and analytical skills, and the ability to interpret new laws and regulations, and communicate effectively both verbally and in writing.

• 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. Exercises patience and consistency in approach and communications.

• Promptly and efficiently react to shifting priorities, demands and time lines using analytical and problem-solving capabilities.

• Ability to effectively prioritize and execute tasks in a fast-paced, dynamic environment.

• Excellent interpersonal and presentation skills.

• Experience working with enterprise databases and analytics.

• Ability to work pro-actively and collaboratively to fulfill the objectives of the Compliance Program and address matters with credibility, objectivity, and confidentiality in accordance with professional auditing and investigative standards.

• Ability to abide by the highest ethical standards and exhibit these standards and the Cancer Service Line mission, vision, and values in the performance of position duties.

• Exhibits a positive attitude and strong work ethic.

Preferred Skills

• Knowledge of medical terminology and electronic medical records.
• Professional and or hospital services auditing experience inpatient and/or outpatient.
• Prior experience working in a Corporate Compliance environment.
• Prior experience working in a cancer service line
• Prior experience working in a Revenue Cycle Operations role.
• Knowledge of Electronic Medical Records

Required Competencies

Ability to work in a team environment and enjoy multi-job functions. Strong Business and Organizational Competence.  Exceptional Customer Service Skills.  Strong functional Competence. Interpersonal Skill Competency. Stress Tolerance. Initiative. Adaptability. Accountability. Integrity. Self-Confidence. Time Management Skills with an emphasis on multi-tasking.

Physical Demands and work environment

The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Physical demands: Required job duties are essentially sedentary in nature, consisting of occasional walking, standing, lifting and/or carrying ten pounds maximum, seeing, speaking and hearing. Must be able to lift up to 25 pounds.

Work environment:  Required job duties are normally performed in a climate-controlled office environment.