Apr 03, 2024

Compliance Auditor

  • Erlanger Health
  • Onsite for at least first 90 days and will transition to hybrid model
Full Time (CPC) Certified Professional Coder (CCS) Certified Coding Specialist (RHIT) Registered Health Information Technician (RHIA) Registered Health Information Administrator Other

Job Description

Compliance Auditor  (39843) -Erlanger Baroness Hospital
Compliance Auditor - Erlanger Health
Regular -   Exempt - Full-time - Standard Hours 37.5

Job Summary:
The Compliance Auditor/Monitor has the primary responsibility of developing, implementing and conducting compliance reviews for both multi-specialty professional services and hospital services under the direction of the Manager of Compliance Auditing and Monitoring Services. All such reviews for both professional and hospital claims must be performed in accordance with requirements of Centers for Medicare and Medicaid (CMS) and the Compliance Audit Methodology. In this role, the Compliance Auditor will lead, provide expert technical skills, and assist with highly visible, sensitive, and multifaceted auditing and monitoring projects. He/She will evaluate compliant billing, documentation, and coding requirements, summarize findings, and propose recommendations for multi-specialty professional services and hospital claims. The Compliance Auditor will help determine if corrective action plans are needed to mitigate any risks identified in the audit. The Compliance Auditor will be responsible to prioritize audit projects, develop audit planning memorandums (e.g., audit methodology) audit programs, and prepare quality audit reports with limited revision. The Compliance Auditor will also be responsible for conducting and/or supporting investigative reviews when non-compliant activity is identified or suspected. This position will interact with all levels of management and employees, external consultants and/or attorneys. This position will be responsible for helping address billing compliance concerns reported to the Office of Compliance and Privacy Services.
The Compliance Auditor will be as assigned / prioritized to perform investigations or incident response, as needed, by the Manager of Compliance Auditing and Monitoring. The Compliance Auditor will also be responsible to provide education and training to Erlanger Health System providers and staff related to appropriate billing, coding, and documentation practices on an ad hoc basis or as needed based on the findings of the compliance auditing activities, regulatory changes, or other similar criteria. The Compliance Auditor must have expertise across multiple professional services lines as well as experience with reviewing hospital services for appropriate use of CPT, HCPCS, ICD-10, APC, MS-DRG, revenue codes, and other required coding to help ensure appropriate documentation, coding, and billing practices.

Degree in Nursing, Health Information Management, Health Information Technician or in other healthcare related field (i.e.). Bachelor Degree required within 1 year of employment. If candidate has extensive hospital coding and auditing experience and applicable coding certification, this may be considered in lieu of bachelor degree.


Three or more years of experience in evaluating and reporting on appropriate billing, coding, and documentation for hospital inpatient/outpatient claims.

Three or more years of experience in evaluating and reporting on appropriate billing, coding, and documentation for professional inpatient/outpatient claims across multiple specialties.

Must demonstrate knowledge of the Center for Medicare and Medicaid Services and other third party payor coding, billing, and documentation criteria.

Experienced in researching Federal, State & Payer coding and reimbursement guidelines and regulations and medical necessity criteria. Ability to compute ratios, percent, and to create and interpret graphs

Ability to define problems, collect data, establish facts and draw valid conclusions

Ability to effectively present information and respond to questions from supervisor and others

Ability to interpret variety of technical instructions or diagram form and deal with several abstract and concrete variables

Ability to use systematic approach to problem solving and troubleshooting

Strong project management skills, along with the ability to take initiative and work independently

High energy level, comfortable performing multifaceted projects in conjunction with day-to-day activities

Excellent interpersonal skills, ability to get along with diverse personalities

Demonstrates positive attitude, and able to interact well and collaborate with other corporate groups (such as Legal Department, Internal Audit, and Human Resources Department)

Able to work on several projects and investigations simultaneously.

Self-motivated; requires limited supervision

Ability to lead and perform special projects including using investigative technics

Ability to work on multiple projects and achieve deadlines

Detail orientated.

Proficiency in Microsoft Word, Excel, Access, Visio and PowerPoint

Five or more years of experience in a compliance auditing and monitoring role or leading a coding team with experience in reviewing hospital and professional inpatient and outpatient claims. Experience and exposure to healthcare compliance concepts and Medicare reimbursement principles. Experience reviewing hospital and professional claims to determine compliance with the requirements for billing services related to patients involved in research.

Knowledge and experience with various electronic health records. Knowledge of RAT-STATS Statically Valid Random Sampling methodology.

Position Requirement(s): License/Certification/Registration
At least one of the following certifications: Registered Nurse (RN), License Practical Nurse (LPN), Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Professional Coder (CPC), Certified Professional Coder-Hospital (CPC-H), Certified Coding Specialist (CCS) certification.

Certified in Healthcare Compliance (CHC) and/or Certified in Healthcare Research Compliance (CHRC).
Prior knowledge and use of MDAudit

Required Experience Level

Intermediate Level