Sr Compliance Auditor

Overview

POSITION SUMMARY: The Sr Compliance Auditor is responsible for auditing the accuracy of assigned diagnostic and procedure codes to records of patients, ensuring compliance with federal, state, and regulatory requirements, payer requirements, and USAP policies and procedures, and providing accurate, meaningful, and timely audit reports and findings to management. This position is also responsible for communicating with management, and providers regarding audit results, new or revised documentation guidelines, and other compliance related information as required.

Job Highlights

ESSENTIAL DUTIES AND RESPONSIBILITIES : ( The ideal candidate must be able to complete all physical requirements of the job with or without a reasonable accommodation)

• Leads and conducts continuous audits on a pre-determined schedule, as well as on an as needed or requested basis, focusing on anesthesia documentation, billing, and coding compliance.

• Evaluates clinical documentation to validate compliance with coding, documentation, and billing laws, regulations, and guidelines to safeguard against fraud, waste, and abuse.

• Contributes to audit planning activities, identifies potential risks areas, and communicates results to compliance leadership.

• Prepares and reviews medical records to assess documentation, coding, and charge accuracy and identify variances.

• Analyzes, prepares, and presents audit reports.

• Develops and delivers targeted communications, training sessions, and educational programs for healthcare providers based on key audit findings in crucial areas, including billing, coding, and medical record documentation.

• Communicates documentation, coding, and charge errors and trends found in audits to compliance leadership.

• Coordinates with compliance leadership to support approval of corrective action plans and liaises with operations to ensure audit findings are remediated, action plans are sustained, and emerging risks are identified.

• Serves as an onboarding peer for new compliance auditors and assists with new compliance auditor training.

• Serves as a subject matter expert, providing guidance and reviewing the work of junior auditors.

• Co-defines and leads preparation efforts for external audits and coordinates information requests.

• Tracks deliverables by the external auditors to facilitate timely completion of external audits.

• Manages audit schedules, maintains accurate records of audit activities, and coordinates meetings and training sessions as needed.

• Serves as a resource for documentation, coding, claim review process, and billing questions, by staying up to date with local, state, and federal laws, regulations, and guidelines. Monitors payer bulletins, periodicals, and websites to maintain knowledge.

• Defines audits, identifies potential risk areas, develops appropriate action plans, documents findings, drafts reports, and communicates results to compliance leadership and/or Compliance Committee.

• Proactively stays current on laws, regulations, and guidance applicable to anesthesia coding, billing, and medical documentation.

• Participates in educational programs and training sessions. Attends other meetings as requested and/or required.

• Co-defines and executes special projects in collaboration with compliance leadership.

• Maintains strict confidentiality of sensitive information, including patient records and audit reports.

• Performs other duties as assigned/requested.

Qualifications

KNOWLEDGE/SKILLS/ABILITIES (KSAs):

• High school diploma or equivalent is required; associate or bachelor’s degree in a related field is preferred.

• 7+ years of anesthesia coding experience or an equivalent combination of education and coding experience. Ideal candidate has experience leading or overseeing audit programs in whole or in part.

• Previous auditing experience required.

• Certification in medical coding (Certified Professional Coder or Certified Coding Specialist) required.

• Advanced certification as a Certified Anesthesia and Pain Management Coder (CANPC) preferred.

• Certified Professional Medical Auditor (CPMA) or Certified Healthcare Auditor (CHA) preferred.

• Expert knowledge of CPT, ASA, and ICD-10 coding, as well as managed care, Medicare, Medicaid, and workers’ compensation billing and coding rules, regulations, and guidance applicable to anesthesia.

• Expert understanding of auditing methodologies and compliance frameworks.

• Strong written and verbal communication skills, including high-level report writing.

• Exceptional critical thinking, problem-solving, and data analysis skills to identify subtle discrepancies and complex coding patterns.

• Advanced research skills in gathering, researching, and reporting information.

• Demonstrates strong time management, prioritization, and organizational skills to manage multiple projects and meet deadlines.

• Ability to independently investigate, analyze, and resolve complex or non-routine issues.

• Proven ability to lead projects, mentor staff, collaborate with diverse departments (coding, clinical, and revenue cycle), and communicate effectively with staff, providers, leadership, and stakeholders at all levels of the organization.

• Working knowledge of computers and the ability to use word-processing, spreadsheets, and data-based programs.

• Maintains high attention to detail and accuracy in all work products.

• Professional demeanor with the ability to work effectively with diverse personalities and in cross-functional environments.

*The physical demands described here are representative of those that may need to be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Occasional Standing

• Occasional Walking

• Frequent Sitting

• Frequent hand, finger movement

• Use office equipment (in office or remote)

• Communicate verbally and in writing