Senior Compliance Coding Auditor CH; REMOTE

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.

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…