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About the Role
The Senior Compliance Coding Auditor conducts independent coding, billing, documentation, and regulatory compliance audits across healthcare practices. This role supports the organization's compliance program through risk-based auditing, monitoring, provider education, and identifying revenue integrity risks. The position serves as a subject matter expert for professional fee coding, documentation, payer regulations, and healthcare compliance standards, partnering with various departments to promote compliant practices.
Responsibilities
- Conduct retrospective and targeted prospective compliance coding audits of professional services.
- Review medical record documentation to validate CPT, HCPCS, ICD-10-CM, modifier assignment, medical necessity, and payer-specific billing requirements.
- Identify coding, documentation, billing, and compliance risks and develop recommendations for improvement.
- Evaluate compliance with CMS, Medicare Administrative Contractor (MAC), Medicaid, and commercial payer regulations.
- Conduct specialty-specific audits including procedural, surgical, and evaluation and management (E/M) services.
- Review provider documentation for completeness, accuracy, and support of services billed.
- Monitor corrective action plans and validate the effectiveness of remediation efforts.
- Participate in annual compliance risk assessments and coding audit plan development.
- Analyze audit findings and identify trends, patterns, and opportunities for focused monitoring activities.
- Collaborate with various departments to ensure accuracy of reported services and assist with chart reviews.
- Communicate audit findings and recommendations to providers, coders, and leadership.
- Develop and deliver coding and compliance education programs for providers, coders, and staff.
- Provide ongoing guidance regarding CPT and HCPCS coding, ICD-10-CM diagnosis coding, E/M documentation requirements, modifier utilization, medical necessity documentation requirements, and specialty-specific coding and billing guidelines.
- Serve as a subject matter expert resource for regulatory and payer-related coding questions.
- Support the implementation and maintenance of the organization’s compliance coding auditing and monitoring program.
- Participate in policy development and revision related to coding and billing compliance.
- Collaborate with Revenue Cycle, Clinical Operations, Quality, Information Technology, Credentialing, Finance, and Legal teams to facilitate compliant coding and billing practices.
- Advise the organization on government coding and billing guidelines and regulatory updates.
- Assist with investigations involving coding, billing, documentation, and reimbursement concerns.
- Monitor regulatory updates and assess organizational impact.
- Support compliance initiatives related to Medicare and Medicaid billing regulations, commercial payer requirements, OIG compliance guidance, documentation integrity, and revenue integrity.
- Participate in the development and enhancement of EHR templates and programming and advise on coding compliance with payor guidelines.
- Report findings and recommendations to compliance and leadership.
- Prepare written audit reports, executive summaries, dashboards, and compliance metrics.
- Present audit results and recommendations to leadership and designated committees.
- Maintain documentation supporting audit methodologies, findings, and corrective action activities.
- Perform other duties as assigned.
Requirements
- Advanced knowledge and demonstrated proficiency in the application of ICD-10-CM, CPT®, and HCPCS Level II coding guidelines, conventions, and regulatory requirements.
- Extensive knowledge of medical terminology, anatomy and physiology, disease processes, pharmacology, and clinical documentation requirements.
- Thorough understanding of Centers for Medicare & Medicaid Services (CMS) regulations, National Correct Coding Initiative (NCCI) edits, Office of Inspector General (OIG) compliance guidance, Medicare and Medicaid policies, and applicable payer-specific coding and billing requirements.
- Strong knowledge of healthcare compliance programs, auditing methodologies, reimbursement principles, and revenue integrity practices.
- Demonstrated ability to conduct complex coding and documentation audits, identify compliance risks, determine root causes, and recommend corrective actions.
- Ability to analyze coding, billing, and audit data; identify trends and patterns; and develop actionable recommendations for process improvement and risk mitigation.
- Strong critical thinking, analytical, problem-solving, and decision-making skills.
- Exceptional attention to detail, accuracy, and organizational skills, with the ability to manage multiple priorities and meet deadlines.
- Excellent verbal, written, presentation, and interpersonal communication skills, including the ability to educate providers, leadership, and staff on coding, documentation, and compliance requirements.
- Proficiency in Microsoft Office Suite, including advanced Excel skills for data analysis and reporting.
- Experience utilizing electronic health records (EHRs), coding systems, auditing software, and compliance monitoring tools.
- Ability to collaborate effectively with clinical, operational, revenue cycle, and compliance stakeholders to support organizational compliance and revenue integrity objectives.
- Ability to interpret and apply evolving regulatory guidance, coding updates, and industry best practices to ensure organizational compliance and revenue integrity.
- Minimum of 5 years of progressively responsible experience in professional coding with demonstrated expert knowledge of procedural and diagnostic coding.
- Minimum of 2 years of coding audit experience, including provider education, documentation review, and evaluation of coding accuracy and regulatory compliance.
- Advanced knowledge of ICD-10-CM, CPT®, HCPCS Level II, National Correct Coding Initiative (NCCI) edits, Medicare Physician Fee Schedule, and applicable payer-specific billing and coding requirements.
- Extensive knowledge of federal and state healthcare compliance requirements, reimbursement methodologies, documentation standards, and audit processes.
Skills
- ICD-10-CM
- CPT®
- HCPCS Level II
- Medical Terminology
- Anatomy and Physiology
- Disease Processes
- Pharmacology
- Clinical Documentation
- CMS Regulations
- NCCI Edits
- OIG Compliance Guidance
- Medicare Policies
- Medicaid Policies
- Payer-Specific Coding and Billing
- Healthcare Compliance Programs
- Auditing Methodologies
- Reimbursement Principles
- Revenue Integrity
- Data Analysis
- Trend Identification
- Problem-Solving
- Critical Thinking
- Attention to Detail
- Organizational Skills
- Microsoft Office Suite
- Advanced Excel
- EHR Systems
- Coding Systems
- Auditing Software
- Compliance Monitoring Tools
- Collaboration
- Regulatory Interpretation
- Coding Updates
- Industry Best Practices
Experience Level
- Senior
Education Level
- Associates Degree
- Higher degree accepted