Compliance Auditor Sr

To be considered for the role, you must permanently reside in one of the following states: Alabama, Arkansas, Florida, Georgia, Kentucky, Kansas, Maryland, Michigan, Mississippi, Missouri, North Carolina, Ohio, South Carolina, Tennessee, Texas, Virginia, or West Virginia. Overview The Senior Compliance Auditor reviews complex audits, performs quality assurance reviews, acts as a peer mentor, and assists management with onboarding process of new auditors. Responsibilities Reviews complex audits, performs quality assurance reviews, and mentors compliance audit team. Supports supervisor with development and maintenance of quarterly audit work plan and audit workflow processes. Recommends changes to improve business operations using professional judgement and best practices. Performs documentation/chart audits on inpatient and outpatient records and provides analysis of provider and facility records. Audits VCUHS coding and billing (DRG, CPT, HCPCS, ICD-10) based on medical record documentation and/or billing claim data. Performs audits of a complex nature as assigned by Compliance Audit Manager and/or Supervisor. Assists Audit Manager with development of the audit schedule by performing ongoing audit software maintenance. Supports Audit Manager with audit team quality assurance reviews. Serves as team liaison for maintenance and troubleshooting of audit software. Acts as a peer mentor and operates with minimal supervision. Conducts audits of hospital and/or physician claims to ensure compliance with federal, state, local, and payor specific requirements. Completes two risk-based audits per month. Serves as the primary backup to the Compliance Educator, leading compliance education sessions for internal coders. Assists with internal training, presenting audit findings, and leading educational sessions when required. Facilitates and improves clinicians, administrators and other appropriate individuals understanding of payor and regulatory requirements by providing feedback related to documentation and billing information. Works with the Compliance Educator to provide educational topics, reviewing materials for department approval, and teaching general compliance education sessions as necessary. Coordinates Corrective Action Plan monitoring schedule and communicates progression to management. Assists departments with identified non-compliant issues in developing Corrective Action Plans. Conducts follow-up reviews to ensure Corrective Action Plans have been implemented. Assists Audit Manager in collaboration with MCVP and MCVH business offices to identify and track trends of external audits. Assists Compliance Audit Supervisor in development of quarterly audit workplan by identifying risks through analysis of external audit and healthcare compliance activities. Sustains a working knowledge of relevant compliance issues, laws and regulations through periodicals, seminars, training programs, and peer contact. Contributes to development and ongoing maintenance of internal Audit Process Manual. Performs onboarding of new auditors as team lead. Completes research and special projects as requested by management. Prioritizes management requests based on urgency and risk. Summarizes findings in appropriate medium and prepares reports. Performs other duties as assigned and participates in special projects to support VCUHS mission. Qualifications Education Required: Bachelor’s Degree in Business, Finance, Allied Health or other health related field from an accredited program. Combination of education and experience may be considered in lieu of a degree. Certification Required: One of the following current AAPC certifications: Certified Professional Coder (CPC), Certified Professional Coder-Hospital (CPC-H), Certified Professional Coder-Payer (CPC-P), CPMA Certified Professional Medical Auditor (CPMA). One of the following current AHIMA certifications: Certified Coding Associate (CCA), Certified Coding Specialist (CCS), Certified Coding Specialist-Physician Based (CCS-P), or other current coding related certification. Minimum Qualifications: Minimum of five years of progressively responsible experience in a healthcare environment, including analysis of electronic health records, risk analysis, audit and quality assessment. Extensive data mining and analytic skills, experience using AI and advanced platforms to enhance efficiency. Comprehensive knowledge of CMS, OIG, and other regulatory guidelines for billing practices. Understanding and identifying diagnostic and procedural codes for clinical services rendered. Proficiency in Microsoft Office Word, Excel, PowerPoint and data collection tools; strong Excel proficiency. Preferred Qualifications: Seven years of progressive risk auditing, coding, and/or coding review experience in CPT, ICD-10, HCPCS and strong data mining skills. Five years previous hospital/physician related work experience in training individuals or groups. Working Conditions Periods of high stress and fluctuating workloads may occur. General office environment. Required to travel to off-site locations, sometimes in adverse weather conditions. May have periods of constant interruptions and prolonged periods of working alone. Physical Requirements Work Position: Sitting. Hazards include depth perception, use of latex gloves, exposure to toxic caustic chemicals, moving mechanical parts, dust fumes, electrical shock, high pitched noises, and gaseous risk exposure. Mental/Sensory – Emotional Strong recall, reasoning, problem solving, hearing, speaking clearly, writing legibly, reading, logical thinking. Able to handle multiple priorities, frequent intense customer interactions, adaptation to frequent change. EEO Employer Disabled Protected Veteran 41 CFR 60-1.4. Patient Population: Not applicable to this position. #J-18808-Ljbffr