Compliance Auditor Sr

Audit Claims & Compliance Requirements

The Senior Compliance Auditor performs audits of a complex nature as assigned by the Compliance Audit Manager and/or Supervisor. They assist the Audit Manager with the development of the audit schedule by performing ongoing audit software maintenance. They support the Audit Manager with audit team quality assurance reviews. They serve as a team liaison for maintenance and troubleshooting of audit software. They act as a peer mentor to the compliance audit team and operate with minimal supervision. They conduct audits of hospital and/or physician claims to ensure compliance with all applicable federal, state, local and payor specific requirements. They complete two risk-based audits per month.

Increases

Serves as the primary backup to the Compliance Educator, leading compliance education sessions for internal coders. Acts as the main backup to the Compliance and Audit Manager, assisting 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, including identifying risk-areas and changes in documentation/coding requirements; reviewing materials for Compliance Department’s approval; and teaching of general compliance education sessions as necessary. Corrective Action For Non-Compliant Issues Identified In Proactive Auditing: Coordinates Corrective Action Plan monitoring schedule and communicates progression to management. Assists management of departments with identified non-compliant issues in developing Corrective Action Plans to correct potential weaknesses and assure ongoing compliance. Conducts follow up reviews to ensure the Corrective Action Plans have been adequately implemented by management.

External Audits

Assists Audit Manager in collaboration with MCVP and MCVH business offices to identify and track trends of external audits. Actively assists Compliance Audit Supervisor in the development of the quarterly audit workplan by identifying risks through analysis of external audit and healthcare compliance activities.

Education

Sustains a working knowledge of relevant compliance issues, laws and regulations through periodicals, seminars, training programs, and peer contact. Researches/special projects: Contributes to the development and ongoing maintenance of the internal Audit Process Manual. Performs as a team lead with onboarding of new auditors. Completes research and/or special projects as requested by management.

Other Knowledge, Skills And Abilities

• Understanding and identifying diagnostic and procedural codes for clinical services rendered
• Previous experience with personal computers and software applications to include Microsoft Word, Excel, PowerPoint, and data collection tools
• Strong excel proficiency is a must
• Seven (7) years of progressive risk auditing, coding and/or coding review experience in CPT, ICD-10; HCPCS coding and strong data mining and analysis skills
• Five (5) years previous hospital/physician related work experience in training individuals or groups

Physical Requirements

• Work Position: Sitting
• Physical Requirements: Additional Physical Requirements/Hazards
• Hazards: Depth perception, Use of Latex Gloves, Exposure to toxic/caustic/chemicals/detergents, Exposure to moving mechanical parts, Exposure to dust/fumes, Exposure to potential electrical shock, Exposure to high pitched noises, Gaseous risk exposure
• Mental/Sensory - Emotional
• Mental / Sensory: Strong Recall, Reasoning, Problem Solving, Hearing, Speak Clearly, Write Legibly, Reading, Logical Thinking
• Emotional: Steady Pace, Able to Handle Multiple Priorities, Frequent and Intense Customer Interactions, Able to Adapt to Frequent Change