Sr Compliance Auditor

Job Summary The Sr Billing Compliance Auditor serves as the liaison responsible for monitoring and auditing NCPS coding and documentation functions for professional fee services. Conducts independent ongoing reviews of vendor and provider‑coded professional fee services to ensure practices meet federal requirements. Works closely with NCPS to communicate monitoring/auditing results and provide feedback to support necessary actions taken accordingly. Functions as the subject matter expert for professional fee coding and documentation, and partners with NCPS administrators to ensure consistent, compliant, and accurate coding practices. Key Responsibilities Conduct audits of NCPS professional fee encounters to validate accuracy of CPT, HCPCS, ICD‑10‑CM, and modifier assignment. Serve as the coding, documentation, and billing expert for NCPS, ensuring focused expertise on pediatric, Florida AHCA / Medicaid, and CMS regulatory requirements. Monitor professional fee vendor‑coding services to ensure alignment with CMS and Florida Medicaid (AHCA) coding, documentation, and billing requirements. Verify that documentation meets regulatory and organizational standards for medical necessity, specificity, and completeness. Adhere to monitoring and audit plans, including routine, focused, and prospective audits. Collaborate closely with NCPS assigned liaison(s) / administrators to ensure timely and effective communication of findings and recommendations for next steps. Prepare trends, error rates, and recommendations for corrective action. Foster a collaborative, solutions‑focused relationship with coding and billing vendors, ensuring a culture of transparency, continuous quality improvement, and shared commitment to accurate, compliant coding practices. Analyze monitoring and auditing data to identify patterns, recurring issues, and opportunities for improvement. Act as a resource to NCPS administrators regarding coding and documentation processes. Maintain current knowledge of CMS, AMA, and AHCA coding, documentation, and billing guidelines; prepare updates of changes to provide to NCPS administrators. Research, analyze, and provide guidance on compliance and coding concerns. Maintain open communication with NCPS administrators and Epic team(s) for any changes or updates to the system that can impact or improve activity of auditors and coding, documentation, and billing processes. Minimum Job Requirements Certified Professional Coder (CPC) and/or Certified Coding Specialist – Physician. 7–10 years of experience with physician (professional fee) billing, coding, documentation, and compliance. 7–10 years of experience interpreting complex regulatory guidelines, relaying applicability of such, and engaging with senior leaders. 7–10 years of experience with proficiency in coding physician practice and surgical procedures. 7–10 years of experience leading and executing internal audits, analyzing findings, and developing, implementing, and monitoring corrective action plans. Knowledge, Skills, and Abilities Bachelor's Degree or Associate Degree, preferred. Strong communication skills. Ability to work independently, demonstrate high-level autonomy, and be proactive. Ability to communicate clearly and courteously (verbal and written) with internal and external customers. Good organizational skills and adaptability to frequent changes in assignments. General knowledge of revenue cycle and pediatric industry experience. Maintain active membership in national association(s) with required CEU credits. PowerPoint and reporting proficiency. Knowledge of managed care regulations regarding patient type criteria and appropriateness of patient type statuses by healthcare professionals when admitting patients as OP, OBS, or IPs. Outstanding analytical and organizational skills with attention to detail. Demonstrable problem‑solving skills. Ability to maintain confidentiality of sensitive information. Ability to interface with compliance and outside auditors. Create, develop, and give presentations. #J-18808-Ljbffr Nicklaus Children's Health System