Compliance Auditor

Job Summary

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 Qualifications

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

Minimum Years of Experience : 3 Years of directly related experience

Substitutable Education & Experience (Optional) : A Bachelors and 3 years of experience can be substituted for the following combinations of education / work experience :

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.

Essential Functions

• 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.

Duties & Responsibilities

• 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 and regulations are discovered to create overpayments.
• Keeps abreast of ICD-10, CPT-4, and HCPCS coding changes, compliance issues and regulations and provides communication and updates regarding changes in regulations, policies or procedures pertaining to the Compliance Program.
• Treats patients, fellow employees and all individuals met while representing the organization with courtesy and respect in keeping with the LMC vision.
• Adheres to organization wide policies.
• Performs all other duties as assigned.

We are committed to offering quality, cost-effective benefits choices for our employees and their families :

• Day ONE medical, dental and life insurance benefits
• Health care and dependent care flexible spending accounts (FSAs)
• Employees are eligible for enrollment into the 403(b) match plan day one. LHI matches dollar for dollar up to 6%.
• Employer paid life insurance equal to 1x salary
• Employee may elect supplemental life insurance with low cost premiums up to 3x salary
• Adoption assistance
• LHI provides its full-time employees employer paid short-term disability and long-term disability coverage after 90 days of eligible employment
• Tuition reimbursement
• Student loan forgiveness
30+ days ago