Certified Medical Auditor

Certified Medical Auditor Position Summary

The Certified Medical Auditor is responsible for conducting comprehensive medical record, coding, billing, and compliance audits to ensure accuracy, completeness, regulatory compliance, and adherence to organizational policies and industry standards. This position reviews clinical documentation and coded data to identify discrepancies, over payments, underpayments, compliance risks, and opportunities for process improvement.

The Certified Medical Auditor works collaboratively with coding, clinical, billing, compliance, and leadership teams to educate staff, improve documentation and coding accuracy, and support ongoing audit and compliance initiatives.

• Conduct prospective, concurrent, and retrospective medical record and coding audits.
• Review medical documentation to validate the accuracy and completeness of ICD-10-CM, CPT, HCPCS, and other applicable coding.
• Evaluate medical necessity, documentation requirements, code assignment, and billing practices.
• Identify coding errors, documentation deficiencies, compliance risks, over coding, undercoding, unbundling, incorrect modifiers, and other billing discrepancies.
• Calculate audit findings, financial impact, error rates, and potential reimbursement implications.
• Prepare detailed audit reports outlining findings, supporting documentation, recommendations, and corrective actions.
• Maintain accurate audit work papers and documentation in accordance with organizational policies.
• Monitor trends and identify recurring coding and documentation issues.
• Provide education and feedback to coders, providers, clinical staff, and billing personnel based on audit findings.
• Assist with the development and implementation of corrective action and performance improvement plans.
• Perform focused and targeted audits based on identified compliance risks or organizational priorities.
• Assist with internal and external audit requests and regulatory inquiries.
• Stay current with changes to coding guidelines, payer policies, CMS requirements, federal and state regulations, and industry standards.
• Participate in coding and compliance education initiatives.
• Collaborate with Compliance, Revenue Cycle, HIM, Clinical Operations, and Coding leadership.
• Maintain confidentiality of patient, provider, employee, and organizational information.
• Support organizational compliance with HIPAA and applicable federal and state regulations.
• Perform additional auditing, coding, compliance, and analytical duties as assigned.

• Certification as a Certified Medical Auditor (CMA) or equivalent recognized auditing certification.
• Strong knowledge of medical coding, documentation, billing, and reimbursement principles.
• Knowledge of ICD-10-CM, CPT, HCPCS, and applicable coding guidelines.
• Understanding of CMS regulations, Medicare/Medicaid requirements, and commercial payer policies.
• Strong analytical, organizational, and problem-solving skills.
• Excellent written and verbal communication skills.
• Ability to interpret medical records and clinical documentation.
• Ability to work independently while effectively collaborating with multidisciplinary teams.
• Strong attention to detail and ability to maintain accurate audit documentation.
• Proficiency with Microsoft Office applications, including Excel and Word.

• Associate or bachelor's degree in health information management, Healthcare Administration, Nursing, Business, or a related field.
• RHIA, RHIT, CPMA, CEMA, CPC, or other relevant coding/HIM certification.
• Experience performing professional, facility, outpatient, inpatient, or risk-adjustment audits.
• Experience with healthcare compliance and regulatory requirements.
• Experience developing audit reports, presenting findings, and providing coding/documentation education.

• Medical coding and auditing methodologies
• Clinical documentation requirements
• Healthcare reimbursement systems
• Regulatory and compliance requirements
• Audit sampling and methodology
• Root-cause analysis
• Data analysis and reporting
• Risk identification and mitigation
• Provider and coder education
• Effective communication and presentation skills
• Confidentiality and HIPAA requirements

The Certified Medical Auditor is expected to:

• Complete assigned audits accurately and within established deadlines.
• Maintain a high level of accuracy and consistency in audit findings.
• Clearly communicate audit results and recommendations.
• Identify opportunities to reduce coding and…