Corporate Compliance Clinical Auditor

Corporate Compliance Clinical Auditor Remote or Hybrid with travel as needed. Our mission: Through the hearts of our Care Team Members, we provide excellent healthcare to those we serve. L - Listening E - Empathy A - Accountability D - Decisiveness This is how we create a culture to LEAD with Love. Position Overview The Corporate Compliance Clinical Audit Specialist is a key member of the Corporate Compliance & Ethics team. This position audits post-acute care facilities to assess adherence to the Office of Inspector General’s (OIG) compliance program requirements for skilled nursing facilities, home health, and hospice. The role involves conducting facility reviews, identifying compliance gaps, and supporting the implementation of best practices aligned with industry standards and organizational policies. Key Responsibilities Compliance Auditing and Oversight Conduct retrospective, concurrent, and prospective audits of medical records across skilled nursing, home health, and hospice settings to assess compliance with billing, coding, documentation, and quality standards. Identify discrepancies, errors, or potential non-compliance with federal/state regulations, payer requirements, and internal policies. Lead and manage internal compliance audits, ensuring timely completion, accurate documentation, and development of corrective action plans. Track audit outcomes and collaborate with stakeholders to implement monitoring strategies that support sustained compliance. Audit Response and Denials Support Support pre- and post-payment audit responses by coordinating documentation, tracking deadlines, and communicating with payers as directed. Collaborate with clinical, billing, and operational teams to gather required documentation. Assist in managing denial responses, including gathering supporting documentation and contributing to appeal strategies. Coordinate responses to external audit requests and ensure timely, accurate submissions. Training and Education Deliver post-audit training sessions tailored to audit findings, focusing on documentation, coding, billing, and regulatory compliance. Develop and present educational materials to care team members on compliance best practices and regulatory updates. Investigations and Policy Development Participate in investigations of potential compliance concerns and evaluate opportunities for proactive auditing. Contribute to the review and enhancement of organizational policies and procedures to improve compliance and operational efficiency. Collaboration and Reporting Prepare and present audit and investigation findings to leadership, including recommendations for corrective actions and process improvements. Collaborate with departments such as Legal, Clinical, IT, Finance, MDS/RAI, Operations, and HR to address compliance issues and implement solutions. Maintain accurate records of audit activities and ensure alignment with HIPAA and regulatory standards. Regulatory Awareness and Support Stay informed on changes in CMS, Managed Care, and other regulatory agency guidelines. Provide support for compliance initiatives and special projects as needed across the organization. Education Bachelor’s degree required; equivalent work experience may be considered. Licenses and Certifications Active clinical license (RN, LPN, PT/OT/ST, etc) Certifications (RAC-CT, RAC-CTA) preferred. Certified in Healthcare Compliance (must be obtained within one year of hire). Experience 4 to 7 years of experience in Medicaid, Medicare, & Managed Care ADRs, Audits, & Denials. Compliance/Healthcare post-acute care experience, including billing, coding, and documentation. Experience with Medicare A/B, Medicare Advantage, and Medicaid (multi-state) coverage criteria, Medicare billing rules, along with documentation standards. Proficiency with electronic health records (PCC) and healthcare documentation systems. RN Preferred. Knowledge, Skills, and Abilities Strong understanding of healthcare regulations, compliance standards, and audit processes. Strong knowledge of MDS, PDPM, and documentation requirements. Excellent analytical and problem-solving skills with attention to detail and accuracy. Effective communication and interpersonal skills across multidisciplinary teams. Ability to work independently and collaboratively in a fast-paced environment. Skilled in managing multiple priorities and meeting deadlines with minimal supervision. Strong organizational, planning, and project management abilities. Ability to build and maintain professional relationships across departments. High level of discretion and ability to handle sensitive and confidential information. Expert-level proficiency in Microsoft Office 365 Suite (Teams, SharePoint, Excel, etc.). Demonstrated ability to remain composed and effective in high-pressure situations. Proactive, resourceful, and solutions-oriented with a focus on continuous improvement. #J-18808-Ljbffr Majestic Care