Inpatient and/or Outpatient Certified Professional Medical Auditor (CPMA)

The Certified Professional Medical Auditor is responsible for performing comprehensive audits of medical records, coding, and billing to ensure accuracy, compliance with federal and state regulations, and alignment with payer policies. This role helps protect the organization from financial risk, supports accurate reimbursement, and promotes high standards of documentation and clinical integrity.

Key Responsibilities

• Perform prospective and retrospective audits of medical records, coding, and billing across assigned service lines (e.g., outpatient, inpatient, behavioral health, SUD/MH, lab).

• Verify that documentation supports ICD‑10‑CM, CPT, and HCPCS coding; identify under‑coding, over‑coding, unbundling, and other compliance risks.

• Review claims for adherence to Medicare/Medicaid, commercial payer, and regulatory guidelines; ensure compliance with NCCI edits and payer‑specific policies.

• Prepare clear, detailed audit reports summarizing findings, financial impact, and recommended corrective actions.

• Collaborate with providers, coders, billers, and leadership to communicate findings and develop education or corrective action plans.

• Deliver one‑on‑one and group education to providers and coding/billing staff on documentation, coding changes, and best practices on site.

• Participate in the development and ongoing refinement of the annual audit plan, using risk‑based methodologies and data analytics (denials, outliers, new services, high‑risk codes).

• Assist with payer audits, responses, and appeals, supplying documentation, coding rationale, and remediation plans as needed.

• Partner with revenue cycle and billing teams on denial management: analyze denial trends (especially for behavioral health/SUD/MH in relation to medical documentation), identify root causes, recommend fixes, and support appeals and resubmissions.

• Monitor and track trends in audit findings, denials, and compliance issues; recommend process improvements to reduce error rates and improve revenue integrity.

• Maintain current knowledge of coding guidelines, compliance regulations, payer updates, and industry best practices; participate in continuing education to maintain CPMA and other credentials.

Required Qualifications

• Current Certified Professional Medical Auditor (CPMA) credential (AAPC), or eligibility and willingness to obtain within an agreed timeframe.

• Minimum 3 years of experience in medical coding, billing, or auditing in a healthcare setting, with strong preference for substance abuse, mental health, and behavioral health programs.

• Strong working knowledge of:

  • ICD‑10‑CM, CPT, HCPCS

  • E/M guidelines

  • NCCI edits and payer policies

  • Medicare and Medicaid billing rules

• High school diploma or equivalent required; Associate’s or Bachelor’s degree in Health Information Management, Healthcare Administration, Nursing, or related field preferred.

• One or more core coding credentials preferred (e.g., CPC, CCS, CCS‑P, CIC, COC).

Preferred Qualifications

• Experience auditing behavioral health, psychiatry, addiction medicine, or SUD/MH programs.

• Experience with auditing, coding, and documentation requirements for Outpatient Physician groups and E&M services.

Key Skills & Competencies

• Exceptional attention to detail and analytical skills.

• Ability to interpret and apply complex regulations and payer policies.

• Strong written skills for audit reports and provider feedback; confident verbal communication for education and difficult conversations.

• High degree of professionalism and confidentiality when handling PHI and sensitive financial data.

• Ability to work independently, manage multiple concurrent audits, and meet deadlines.

• Proficiency with EHRs, billing systems, and audit tools (Excel, audit software, data analytics reports).

Physical & Work Environment Requirements

• Primarily office, extensive computer and document review.

• Medical and Clinical education sessions.