Compliance Auditor

Performs comprehensive audit of care center locations/divisions. Reviews patient chart documentation for accuracy of Evaluation and Management (E/M) service levels, modifier use, in-office procedures, and diagnosis codes for services performed by OB/GYN physicians and other qualified healthcare providers. Evaluate key administrative, operational, compliance, and regulatory requirements. Communicates with providers verbally and in written report format. Informs leadership and the Executive team of audit findings, potential deficiencies, develops and monitors corrective action plans. Communicate with upline management of identified trends and areas of risk. Provides recommendations for improvement in the patient experience, clinical outcomes, and the documentation system to mitigate risk to the Company.

Attributes/Qualifications:

To perform this professional position successfully, an individual must be able to perform each primary responsibility/job function accurately and consistently at an independent level. Knowledge of physician group practice, standards of medical record maintenance and documentation, medical coding per Current Procedural Terminology (CPT) and the International Classification of Diseases, Tenth Edition (ICD-10) standards, reimbursement concepts, commercial payer medical policies, and local/state/federal regulatory requirements. Demonstrated organizational skills, ability to meet deadlines, multi-task with the ability to prioritize, and work independently in a remote environment. Excellent verbal/written communication and presentation skills are required. Minimal travel may be required.

Required Education/ Experience:

Certified Professional Coder (CPC) credentialed with a minimum of three years of medical coding experience in the area of specialty or similar certification with the ability to obtain the CPC within six months from the hire date. All auditors must maintain a valid and current coding certification. OB/GYN experience and the Certified Professional Medical Auditor (CPMA), Certified Obstetrics and Gynecology Coder (COBGC)

certifications or the like are preferred. Experience in surgical coding is a plus. Recommend having at minimum a bachelor’s degree in business or healthcare administration, or a related field.

Responsibilities

• Reviews patient chart documentation for accuracy
• Communication and coordination of provider education sessions and written summaries
• Research applicable policies and regulations
• Administrative - team meetings

Additional Job Functions:

• Attends periodic training sessions.
• Other duties as assigned.

Qualifications

• Abides by and demonstrates the Company's Mission, Vision, and Values through both professional behavior and job performance on a day-to-day basis to meet all expectations of the position.
• Conducts complete and timely comprehensive audits with the ability to consistently meet coding standards of 90% accuracy and provide coding and documentation education.
• Performs pre-and post-billing chart reviews to ensure the clinical documentation provides evidence of compliance with coverage requirements, Company policy, and regulatory requirements including evaluation and management, surgery, radiology, pathology, and medicine.
• Ability to research, apply and keep abreast of all Company policies/procedures, local/state/federal laws/regulations, and serves as a resource to care center locations/divisions in these areas.
• Communicate with the Compliance/Legal Department any reportable findings or matters identified during the audit that would put the Company at risk.
• Communicates and informs the care center locations/divisions and leadership of audit findings and corrective action plans.
• Prepares accurate, concise, and timely written executive summary of findings and coordinates all provider education sessions.
• Provides feedback to the Compliance Department and Company departments regarding recommended revisions or updates to Company policies, education opportunities, and documentation system enhancements.
• Adheres to all Company’s policies and procedures, the Code of Conduct, the Employee Handbook, the mandatory Ethics and Compliance, and HIPAA privacy and security programs.
• Participates in special projects and performs other duties as assigned.