COMPLIANCE SPECIALIST-Remote

At Duke Health, we're driven by a commitment to compassionate care that changes the lives of patients, their loved ones, and the greater community. No matter where your talents lie, join us and discover how we can advance health together with the Patient Revenue Management Organization, a fully integrated, centralized revenue cycle team supporting the entire health system in scheduling, registration, coding, billing, and other essential revenue functions. This position is 100% remote; all Duke University remote workers must reside in one of the following states: North Carolina, Alabama, Arizona, Connecticut, District of Columbia, Florida, Georgia, Illinois, Iowa, Kentucky, Louisiana, Maine, Michigan, Missouri, Montana, New Hampshire, Ohio, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, or Washington. A $10,000 sign-on bonus is offered, paid in four equal installments over 24 months at 6-month intervals.

About the Role

The Compliance Specialist Auditor will perform coding quality audits of inpatient records to ensure appropriate and accurate code assignments in accordance with Center for Medicare and Medicaid Services (CMS) guidelines. The role provides ongoing feedback and identifies education needs for providers and staff.

Responsibilities

• Conduct monthly quality assurance audits of professional billing (PB) coders.
• Monitor data quality and optimal reimbursement by performing retrospective quality audits for accurate coding of ICD-10-CM diagnoses, CPT-4 procedures, and appropriate use of modifiers for professional and outpatient services, following CMS coding guidelines, standards, and regulations.
• Utilize coding resources to substantiate audit findings.
• Perform medical record reviews to ensure documentation supports assigned codes.
• Conduct focused and integrated audits as necessary.
• Serve as a subject matter expert on coding and collaborate with outside departments.
• Address coding questions and provide expert guidance.
• Identify coding and billing risk areas and report results to PB Operations for action planning.
• Analyze coded records for compliance with federal, state, and third-party insurer rules and regulations; note trends.
• Demonstrate excellent verbal and written communication.
• Model ethical behavior and promote a culture of compliance.
• Identify issues and facilitate timely, constructive resolution.
• Perform other related duties as assigned.

Requirements

• High School Diploma (required).
• Four (4) years of coding review experience applying compliance, auditing, and coding principles related to professional coding and billing, or an equivalent combination of relevant education and/or experience.

Qualifications

• Certified Professional Coder (CPC), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), and/or Certified Coding Specialist (CCS) (required).
• Certified Risk Coder (CRC) or Certified Professional Medical Auditor (CPMA) (preferred).
• Knowledge of ICD-10-CM and CPT/HCPCS coding guidelines for outpatient diagnoses and procedures.
• Understanding of prospective payment systems, DRG/APC reimbursement methodologies, and coding validation.
• Familiarity with anatomy, physiology, pharmacology, and medical terminology.
• Proficiency in analyzing detailed information to ensure compliance with coding and reimbursement regulations.
• Ability to establish and maintain effective working relationships and communicate clearly.
• Experience identifying trends within audits.
• Epic experience preferred; familiarity with 3M 360 CAC, Audit Manager, and MS Office applications (Word, Excel, Visio, Access, PowerPoint).

Skills

Highly sought-after skills include:

• HCC coding/auditing.
• Multi-specialty coding/auditing, with examples such as:
  • Interventional Radiology.
  • Cardiothoracic.
  • Orthopedics (Foot and Ankle specifically).
  • Critical Care.
  • Observation Services.
  • Emergency Department (ED).
  • Edits/Denials.
  • General Surgery.
  • Trauma.
  • Pediatrics.
  • Gastrointestinal (GI).
  • Anesthesia.
• Strong work ethic and sense of responsibility.
• Ability to work independently.