高级合规编码审计员 CH
Senior Compliance Coding Auditor CH
概述
向医疗合规总监汇报，高级合规编码审计师负责对门诊和专科护理实践进行独立的编码、计费、文件记录和监管合规性审计。该职位通过基于风险的审计、监控、提供者教育、计费问题调查、收入完整性风险识别以及纠正措施计划的制定，支持组织的合规项目。高级合规编码审计师是专业费用编码、文件记录要求、政府和商业保险公司法规以及医疗合规标准的专家。该职位与医生、高级执业提供者、诊所管理层、收入周期、编码、临床运营和高管领导密切合作，以促进合规的计费和文件记录实践。
职责
核心职责：
审计与监控
• 对专业服务进行回顾性和针对性前瞻性合规编码审计（即基线、常规周期性、监控和聚焦性审计）
• 审查医疗记录文件，验证CPT、HCPCS、ICD-10-CM、修饰符分配、医疗必要性以及保险公司特定的计费要求
• 识别编码、文件记录、计费和合规风险，并提出改进建议
• 评估对CMS、医疗保险行政承包商（MAC）、医疗补助和商业保险公司法规的遵守情况
• 进行专科特定的审计，包括程序性、手术和评估与管理（E/M）服务
• 审查提供者的文件记录，确保其完整性和准确性，并支持所计费的服务
• 监督纠正措施计划并验证补救措施的有效性
• 参与年度合规风险评估和编码审计计划的制定
• 分析审计结果，识别趋势、模式和有针对性的监控活动机会
• 与所有部门紧密合作，包括但不限于临床服务、护理、诊所管理层、财务、IT、培训、收入周期和计费，协助确保报告服务的准确性，并根据要求进行病历审查。提供者和编码教育与咨询
• 向医生、高级执业提供者、编码员、管理层和运营团队传达审计结果和建议
• 为提供者开发并提供编码和合规教育项目
查看英文原文
Overview
Reporting to the Director of Healthcare Compliance, the Senior Compliance Coding Auditor is responsible for conducting independent coding, billing, documentation, and regulatory compliance audits across ambulatory and specialty care practices. The position supports the organization's compliance program through risk-based auditing, monitoring, provider education, investigation of billing concerns, identification of revenue integrity risks, and development of corrective action plans. The Senior Compliance Coding Auditor serves as a subject matter expert for professional fee coding, documentation requirements, government and commercial payer regulations, and healthcare compliance standards. This role partners closely with physicians, advanced practice providers, practice leadership, revenue cycle, coding, clinical operations, and executive leadership to promote compliant billing and documentation practices.
Responsibilities
Essential Functions:
Auditing and Monitoring
•Conduct retrospective and targeted prospective compliance coding audits (i.e. baseline, routine periodic, monitoring, and focused) 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 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
•Work closely with all departments, including but not limited to, Clinical Services, Nursing, Practice Leadership, Finance, IT, Training, Rev Cycle, and Billing to assist in accuracy of reported services and with chart reviews, as requested. Provider and Coding Education and Consultation
• Communicate audit findings and recommendations to physicians, advanced practice providers, coders, leadership, and operational teams
• Develop and deliver coding and compliance education programs for providers, coders, and staff
• Provide ongoing guidance regarding: o CPT and HCPCS coding o ICD-10-CM diagnosis coding o E/M documentation requirements o Modifier utilization o Medical necessity documentation requirements o Specialty specific coding and billing guidelines
• Serve as a subject matter expert resource for regulatory and payer-related coding questions
• Work with the purchasing department to order and distribute annual coding materials for all clinical sites and departments.
Compliance Program Support
• Support 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 as necessary to facilitate compliant coding and billing practices
• Advise organization of 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: o Medicare and Medicaid billing regulations o Commercial payer requirements o OIG compliance guidance o Documentation integrity o Revenue integrity
EHR and Documentation Intergrity
• Participate in the development and enhancement of EHR templates and programming and advise on coding compliance with payor guidelines. Reporting
• 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.
Knowledge, Skills and Abilities:
- 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.
Qualifications
Education:
· Associates Degree (higher degree accepted)
Required Work Experience:
- 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.
Require License and Ceritifcations:
· Certified Professional Coder (CPC®) through AAPC
Originally posted on Himalayas