Internal Auditor, Corporate Compliance Billing & Coding

PURPOSE OF POSITION:

The Coding and Billing Compliance Auditor plays a critical role in ensuring the accuracy, integrity, and regulatory compliance of clinical documentation, coding, and billing practices across the health system. This position is responsible for conducting audits, identifying discrepancies, and providing education to staff to reduce risk, prevent fraud, and optimize reimbursement. By maintaining adherence to federal and state regulations, payer guidelines, and internal policies, the auditor helps safeguard the organization’s financial health and promotes ethical, transparent operations across all departments.

PRIMARY DUTIES AND RESPONSIBILITIES:

1. Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers.
2. Challenges current working practices identifies process improvement opportunities and presents recommendations and solutions to management. Engages and commits to the organization’s culture of continuous improvement by actively participating, supporting, and promoting CCHC Pillars of Excellence.
3. Conduct regular audits of medical records, coding, and billing practices to ensure accuracy and compliance with federal, state, and payer regulations.
4. Evaluate claims for compliance with ICD-10, CPT, HCPCS, and other applicable coding standards, identifying coding errors, documentation deficiencies, and billing discrepancies.
5. Perform both scheduled and impromptu audits of physician and coder documentation to verify accuracy, compliance, and appropriate code assignment.
6. Monitor adherence to internal policies, procedures, and the organization’s Code of Conduct, tracking regulatory changes to maintain ongoing compliance.
7. Assist with risk assessments and internal investigations related to billing, coding, and documentation practices.
8. Prepare comprehensive audit reports summarizing findings, trends, and recommendations, maintaining detailed documentation of audits, corrective actions, and follow-up activities.
9. Present findings to leadership, compliance committees, and other key stakeholders, ensuring transparency and accountability.
10. Provide timely feedback and education to coders, billers, and clinical staff on documentation and coding requirements.
11. Develop, implement, and evaluate training programs addressing coding standards, compliance updates, and audit outcomes.
12. Serve as a knowledgeable resource for coding and reimbursement inquiries, offering guidance and recommendations as needed.
13. Collaborate with Revenue Cycle, Health Information Management (HIM), Clinical Documentation Improvement (CDI), and Compliance teams to promote accuracy and consistency across functions.
14. Support external audits and respond to payer or government inquiries in coordination with legal and regulatory teams.
15. Utilize audit software and data analytics tools to identify patterns of risk, noncompliance, or revenue loss, and recommend process improvements to enhance accuracy and reduce denials.
16. Provide coding support and perform related duties as required.
17. Assist with other departmental or organizational initiatives as reasonably assigned.

EDUCATION/EXPERIENCE/TRAINING:

• Ability to read, write and communicate in English
• Bachelor’s degree (or higher) preferably in Law, Healthcare, Compliance, Finance, Business, or Accounting or equivalent combination of education and work experience.
• Minimum of five years’ experience in physician coding, including auditing experience
• Current certification: CPC (Certified Professional Coder) through AAPC or CCS-P (Certified Coding Specialist – Physician-based) through AHIMA
• (Preferred) – Specialty in E&M CEMC (Certified Evaluation and Management Coder) through AAPC, or CPMA (Certified Professional Medical Auditor) through AAPC
• Comprehensive knowledge of coding standards including ICD-9 and ICD-10, CPT, and physician billing requirements, as well as physician reimbursement methodologies
• Strong verbal and written communication skills, with the ability to effectively interact with a wide range of individuals across clinical and administrative settings
• Proficiency with software applications related to electronic health records (EHR) and billing systems to ensure accurate documentation and reporting
• Proven ability to develop and deliver training materials that enhance understanding and compliance in coding, billing, and documentation practices.
• Skilled in building and maintaining positive working relationships with physicians and interdisciplinary teams to promote collaboration and adherence to compliance standards
• Performs other related duties as assigned or requested to support departmental and organizational goals

Schedule Details:

Full-Time, Monday-Friday, Occasional Evenings, Weekends, & Occasional Holidays

Pay Range Details:

The pay range displayed on each job posting reflects the anticipated range for new hires. A successful candidate’s actual compensation will be determined after taking factors into consideration such as the candidate’s work history, experience, skill set, and education. This is not inclusive of the value of Cape Cod Healthcare’s benefits package (if applicable), which includes among other benefits, healthcare/dental/vision and retirement. For annual salaries this is based on full-time employment.