Prof Coding Compliance Auditor

Primary function:
Reporting to the Manager Compliance Audit and Analysis develops and executes audit monitoring and education for professional billing coding and documentation programs that confirm compliance identifies reimbursement implications and provides billing providers with relevant and timely information regarding audit results and risk areas. Serves as a resource for providers on professional billing and coding.

Principal duties and responsibilities:
- Prepares and oversees professional billing and coding components of the Compliance work plan reflecting scheduled activities and target dates.
- Leads focused audits and reviews to assess adherence with professional billing compliance policies legal and regulatory requirements and to identify and evaluate risk areas.
- Assists in development of organizational compliance auditing and monitoring activities for professional billing and coding including periodic reviews of the individual department auditing and monitoring functions.
- Coordinates sample reviews to ensure codes that were billed are properly supported by appropriate provider documentation.
- Creates audit result reports to be reviewed with providers.
- Organizes and schedules audit findings/education sessions with providers to review audit results.
- Conducts sample and focused reviews to ensure provider coding and billing is compliant with government and payor guidelines.
- Analyzes and reviews medical record documentation and billing data for all pertinent internal and external audits.
- Collaborates with clinical and administrative staff and leadership to ensure audit results are disseminated and understood.
- Manages investigations and audit findings in MDAudit and communicates with the Manager Compliance Audit and Analysis if audit findings need to be escalated and entered into the Departments issues tracking system.
- Supports professional billing compliance education including auditing trending and feedback to providers and professional coders. Manages and fosters relationships with internal professional coders coding educators and managers and third-party clinical reviewers.
- Assists with development and delivering educational and training programs for professional billing and clinical compliance based on the latest Federal and State regulations to appropriate providers and caregivers.
- Collaborates with other staff who may be conducting focused professional billing compliance audits and/or other special projects included in the annual departmental work plan.
- Maintains required credentials participates in continuing education opportunities to remain current with billing and coding compliance best practices (i.e. conferences workshops and other professional development activities).
- Actively participates in departmental meetings and activities attends meetings and in-service/educational programs and other activities as requested.
- Maintains confidentiality of patient/members and staff information.
- Performs assigned work safely adhering to established departmental safety rules and practices; reports to supervisor in a timely manner any unsafe activities conditions hazards or safety violations that may cause injury to oneself other employees patients and visitors.
- Performs other related duties as required.

Education and experience requirements:
- Current Professional Coders (CPC) or other relevant and industry-recognized certification required.
- Minimum of three (3) years of experience with audit activities required.

Preferred Experience:
- Bachelors degree preferred.
- Certification in Healthcare Compliance preferred.

Knowledge skills and ability requirements:
- Knowledge of legal regulatory and policy compliance issues related to coding billing procedures and documentation.
- Ability to clearly communicate coding information including the results of coding compliance audit activities.
- Proficiency in root cause analysis critical thinking and gaining acceptance of recommended solutions.
- Team player and understands role in relationship to others.
- Strong interpersonal and communication skills.
- Clear concise and persuasive writing and presentation skills.
- Strong orientation to deadline and detail.
- Strong organizational and project management skills.
- Working knowledge of computer software Word Access Excel PowerPoint; as well as EMR.
- Knowledge of healthcare financial management principles/practices.
- Ability to work in highly matrixed environments.
- Ability to be flexible and adapt to change.

- Proficient in MDAudit Enterprise software and Epic electronic health record systems.
- Thorough knowledge of coding documentation improvement practices.
- Thorough knowledge and understanding of billing coding and documentation requirements Federal and State regulations unbundling edits medical necessity clinical best practices and professional billing requirements.
- Project management experience preferred



PHYSICAL REQUIREMENTS (Medium Max 25lbs): up to 25 lbs. 0-33% of the work day (occasionally); 11-25 lbs. 34-66% of the workday (frequently); 01-10 lbs. 67-100% of the workday (constantly); Lifting 25 lbs. max; Carrying of objects up to 25 lbs.; Occasional to frequent standing & walking Occasional sitting Close eye work (computers typing reading writing) Physical demands may vary depending on assigned work area and work tasks.



ENVIRONMENTAL FACTORS: Factors affecting environmental conditions may vary depending on the assigned work area and tasks. Environmental exposures include but are not limited to: Blood-borne pathogen exposure Bio-hazardous waste chemicals/gases/fumes/vapors Communicable diseases Electrical shock Floor Surfaces Hot/Cold Temperatures Indoor/Outdoor conditions Latex Lighting Patient care/handling injuries Radiation Shift work Travel may be required. Use of personal protective equipment including respirators environmental conditions may vary depending on assigned work area and work tasks.