Compliance Auditor

Corporate Compliance

Full Time

Day Shift

7am - 5pm

Lexington Health is a comprehensive network of care that includes six community medical and urgent care centers, nearly 80 physician practices, more than 9,000 health care professionals and Lexington Medical Center, a 607‑bed teaching hospital in West Columbia, South Carolina. It was selected by Modern Healthcare as one of the Best Places to Work in Healthcare and was first in the state to achieve Magnet with Distinction status for excellence in nursing care.

Consistently ranked as best in the Columbia Metro area by U.S. News & World Report, Lexington Health delivers more than 4,000 babies each year, performs more than 34,000 surgeries annually and is the region's third largest employer.

Lexington Health also includes an accredited Cancer Center of Excellence, the state’s first HeartCARE Center, the largest skilled nursing facility in the Carolinas, and an Alzheimer’s care center. Its postgraduate medical education programs include family medicine and transitional year residencies, as well as an informatics fellowship.

Analyze and audit LMC systems of the Physician Network and the hospital medical record data to determine if charges billed are supported by appropriate medical documentation. Monitors risk areas and conducts focused audits as identified by the Compliance Audit Manager. Prepares reports and meets with physicians and Advanced Practice Providers (APPs) to review audit results.

Minimum Education
:
Bachelor’s Degree in Business or Related Field

Minimum Years of Experience
: 3 Years of directly related experience

Substitutable Education & Experience (Optional):

• High School Diploma with 7 years of directly related experience;
• Associate’s Degree with 5 years of directly related experience.

Required Certifications/Licensure
:
Certified Professional Coder (CPC) Certification through AAPC or Certified Coding Specialist (CCS) through AHIMA

Certified Professional Medical Auditor (CPMA) Certification (Not required at placement into the role, but must be obtained within 1 year of entry date).

Required Training
:
Strong problem solving skills;
Ability to articulate orally and in writing an understanding of complex issues and detailed action plans, while representing the organization professionally. Must be able to communicate with physicians, Advanced Practice Providers (APPs), senior administrators and department staff;
Proficient in Microsoft Office.

• Responsible for conducting audits of hospital and Physician Network records to determine whether services provided to patients are appropriately documented and billed in accordance with Medicare, Medicaid, and third party billing regulations and/or standards.
• Assists the Chief Compliance Officer in investigating inquires which may relate to erroneous billing and coding of services.
• Works closely with other departments, Health Information Management and Revenue Integrity to conduct coding reviews and inquires.
• Drafts formal written reports that summarize medical record findings for review.
• Provides education on subjects pertinent to reviews conducted and any coding and billing changes to appropriate LMC staff.
• Determines whether medically necessary criteria are met as required by CMS and the fiscal intermediary through National Coverage Determinations (NDCs), Local Coverage Determinations (LCDs) and other guidance in effect at the time of the review.

• Participates in risk assessment of areas of focus designated by the Recovery Audit Contractors, MIC, OIG, ZPIC and other regulatory agencies.
• Consults with the Revenue Integrity personnel and the Compliance Audit Manager when relevant issues of federal and state health care billing law…