The Compliance Auditor is responsible for planning and conducting audits of companys clinical and administrative processes, including coding and billing.
compliance, documentation, medical necessity, adherence to internal policies, procedures and
guidelines, services provided by outside vendors including companys revenue cycle vendor, and
compliance with state and federal regulations including HIPAA Privacy and Security. The
Compliance Auditor is responsible for preparing and submitting written audit reports that include
findings and recommendations, communicating findings to the Director, developing and
implementing corrective action plans when necessary, and following up to ensure that corrective
plans are implemented and were effective.
JOB RESPONSIBILITIES:
Implement the Audit Process
Plan and schedule audits, including identifying the audit subject and purpose, defining audit
objective(s), defining audit scope, performing preaudit planning, and notification to the
area(s) to be audited.
Conduct audits, including meeting with impacted employees and keeping impacted
organizational areas(s) apprised along the way of any findings and urgent actions to be taken
if necessary.
Develop audit reports that includes findings, recommendations designed to correct any
potential weaknesses or areas of noncompliance discovered during the audit, request for
management response to each finding or recommendation including corrective action plan(s)
to be developed and implemented.
Provide followup prior to closing the audit including confirming successful implementation
of corrective action plans, verify that management responses are implemented, and assess
new processes, procedures and actions.
Stay Abreast of Applicable Regulatory Changes
Maintain current knowledge of medical documentation, fraud, abuse, and documentation and
coding violations based on governmental guidelines, including State and Federal
overpayment regulations.
Stay abreast of and maintain current knowledge of Medicare and Medicaid guidelines.
applicable to companys Pain Management Clinics and Ambulatory Surgical Centers (ASCs),
including applicable Local Coverage Determinations (LCDs).
Maintain current knowledge of requirements and guidance required in the performance of
audit duties, including but not limited to ICD10, HCPCS, and CPT coding, modifiers, and
surgical procedures documentation requirements.
Maintain current knowledge of HIPAA Privacy and Security Requirements.
Conduct Audits
Review medical records to determine the medical necessity of services billed and the
accuracy of coding, billing, and supporting clinical documentation in either an Ambulatory
Surgical Center (ASC) or a Pain Management Clinic.
Review records that have been reviewed and coded by the revenue cycle vendor.
Review companys practices, procedures, and materials for compliance with CMS and HIPAA
regulations.
Prepare audit reports of findings and observations that identify, in detail, areas of non
compliance and risk areas for noncompliance.
Ensure corrective actions are implemented and effective.
Conduct other audits as assigned, including but not limited to contract reviews, lease
agreements, compliance with contract language, etc.
Share departmental responsibilities as assigned.
JOB REQUIREMENTS:
Bachelor s degree in accounting, business administration, or healthcare related field required.
AAPC Certified Professional Coder (CPC ) or AHIMA Certified Coding Specialist
Physicianbased (CCSP) certification, required.
Certified Professional Medical Auditor (CPMA) certification preferred.
Healthcare compliance certification, a plus.
A strong understanding of healthcare regulations, such as HIPAA, Medicare, Medicaid, and
other relevant industry standards, is essential.
Solid grasp of auditing principles, techniques, and methodologies.
