Compliance Auditor Sr

Senior Compliance Auditor

The Senior Compliance Auditor reviews complex audits, performs quality assurance reviews, acts as a peer mentor, and assists management with onboarding process of new auditors. The Senior Compliance Auditor supports the audit supervisor with the development and maintenance of the quarterly audit work plan and audit workflow processes. The Senior Compliance Auditor recommends changes to improve business operations by using professional judgement and knowledge of best practices. This position contributes to special projects, as applicable. The Senior Compliance Auditor performs documentation/chart audits on inpatient and outpatient records, and to provide analysis of the records (provider and facility) reviewed, education and other assistance, as needed. The Senior Compliance Auditor audits VCUHS coding and billing (DRG, CPT, HCPCS, ICD-10) based on a review of medical record documentation and/or billing claim data.

Essential Job Statements

Audit Claims & Compliance Requirements:

• Performs audits of a complex nature as assigned by Compliance Audit Manager and/or Supervisor.
• Assists the Audit Manager with development of the audit schedule by performing ongoing audit software maintenance.
• Supports the Audit Manager with audit team quality assurance reviews.
• Serves as team liaison for maintenance and troubleshooting of audit software.
• Acts as a peer mentor to the compliance audit team and operates with minimal supervision.
• Conducts audits of hospital and/or physician claims to ensure compliance with all applicable federal, state, local and payor specific requirements.
• Completes 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 weakness 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
• Research/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.
  • Prioritizes management requests based on urgency and/or risk established by Compliance Services, VCUHS Administration or the requesting agency.
  • Gathers information from the correct source(s) and summarizes and prepares findings in an appropriate medium
• Miscellaneous Responsibilities
  • Performs other duties as assigned and/or participates in special projects to support the mission of VCUHS and the Department.
  • Aids team members. Accepts alternate assignments, as required, graciously

Employment Qualifications

Education Required:

Bachelor's Degree in Business, Finance, Allied Health or other health related field from an accredited program

Combination of education and experience may be considered in lieu of a degree.

Education Preferred:

Licensure Required: N/A

Licensure Preferred:

Certification Required:

Licensure, Certification, or Registration Requirements for Hire:

One (1) of the following current AAPC certifications:

• Certified Professional Coder (CPC)
• Certified Professional CoderHospital (CPCH) Certified Professional CoderPayer (CPC-P)
• CPMA Certified Professional Medical Auditor (CPMA) OR

One (1) of the following current AHIMA current certifications:

• Certified Coding Associate (CCA)
• Certified Coding Specialist (CCS)
• Certified Coding SpecialistPhysician Based (CCS-P) OR
• Other current coding related certification

Certification Preferred:

Minimum Qualifications

Years and Type of Required Experience:

Minimum of five (5) years of progressively responsible experience in a healthcare environment to include, but not limited to, the following:

Working with electronic health records to analyze and interpret clinical documentation for compliance purposes.

Extensive data mining and analytic skills combined with experience using AI and advanced platforms focused on driving innovation and enhancing work efficiency.

Conducting audits and investigations of medical records to ensure compliance, with an emphasis on risk analysis and quality assessment thorough workflow evaluation and process improvement.

Comprehensive knowledge of CMS, OIG, and other regulatory guidelines to support compliant billing practices, with proven ability to interpret and analyze complex regulatory information effectively.

Other Knowledge, Skills and Abilities Required:

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.

Other Knowledge, Skills and Abilities Preferred:

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

Working Conditions

Periods of high stress and fluctuating workloads may occur.

General office environment.

Required to car travel to off-site locations, occasionally in adverse weather conditions.

May have periods of constant interruptions.

Prolonged periods of working alone.

Physical Requirements

Physical Demands:

Work Position: Sitting

Additional Physical Requirements/ Hazards

Physical Requirements:

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

EEO Employer/Disabled/Protected Veteran