Healthcare Compliance Auditor

The Healthcare Compliance Auditor position is a staff consulting position within the Healthcare Transactions and Strategy (HTS) group. HTS is currently seeking a Healthcare Compliance Auditor at either the Consultant or Managing Consultant level.

HTS performs regulatory, reimbursement, data analytics, and compliance auditing for healthcare providers, healthcare payers and healthcare investors. Compliance audit deliverables include assessment of provider compliance programs and auditing of billing and coding of clinical documents and claims documents.  This position requires a highly motivated problem solver with strong analytical ability, solid organizational skills, and a desire to advance within the organization. The work of a Healthcare Compliance Auditor will involve execution of engagement work streams that will primarily involve employing certified coding skills to audit provider claims and provider clinical documentation with a particular focus on government programs such as Medicare and Medicaid. Responsibilities include working with team to develop audit specifications, expert analysis of healthcare claims and supporting documentation, quality control, and development of client deliverables.

The work of a Consultant involves execution of engagement work streams that may be either qualitative or quantitative in nature, and responsibilities include: billing and coding audits, compliance program review, quality control, development of client deliverables, and industry research. The work of a Managing Consultant involves both execution and oversight of engagement work streams that may be either qualitative or quantitative in nature, and responsibilities include: management of junior staff, quality control, development and presentation of client deliverables, and industry research.

This specific position will require knowledge of medical coding and compliance and potential candidates must have medical auditing expertise. Job title and compensation to be determined based on qualifications and experience.

Job Responsibilities:

• Plan and perform medical record audits to determine coding accuracy and compliant claims submission;

• Develop coding and documentation audit methodology using knowledge of key risk areas in coding and documentation compliance;

• Perform coding and documentation audits, reviewing medical records and charges to ensure compliance with CPT-4/HCPCS and ICD-10-CM coding guidelines and standards, as well as the Centers for Medicare & Medicaid Services (CMS) coverage guidelines;

• Conduct analysis of audit findings to identify trends/problems in coding and documentation and effectively communicates the audit findings and recommended areas for improvement;

• Serve as a subject matter expert on interpretation and application of coding and documentation guidelines;

• Monitor relevant resources, publications, and current government compliance and enforcement activity related to high-risk compliance areas;

• Stay current on coding guidelines.

• Develop analyses using transactional data and/or financial data;

• Generate client deliverables and make valuable contributions to expert reports;

• Manage client relationships and communicate results and work product as appropriate;

• Manage junior staff and delegate assignments as directed by more senior managers;

• Demonstrate creativity and efficient use of relevant software tools and analytical methods to develop solutions;

• Participate in group practice meetings, contribute to business development initiatives and office functions such as staff training and recruiting;

• Prioritize assignments and responsibilities to meet goals and deadlines.

Qualifications:

• An undergraduate degree (e.g., BS, BA);

• Active coding certification from either AAPC or AHIMA is required;

• Preference will be given to candidates that are certified in medical auditing;

• 2+ years of work experience with a focus on healthcare provider billing and coding;  5-7 years of experience is required for the Managing Consultant level position. Job title to be determined based on relevant qualifications and experience.  

• Preference will be given to candidates that are experienced with physician practice coding (e.g. primary care, dermatology, orthopedics, ophthalmology), ASC coding, and/or post-acute coding (e.g. hospice, home health, SNFs).

• Comprehensive knowledge of Medicare rules, regulations, and guidelines as they apply to coverage, coding, and provider documentation.

• Advanced knowledge of CPT-4, HCPCS, and ICD-10-CM coding systems, guidelines, and regulatory requirements.

Required skills include: 

• Demonstrated ability to interpret national coding and documentation guidelines and translate them into effective auditing practices and tools; identify issues in coding and documentation practices and recommend corrective action; develop reports, track, and trend audit findings and results.

• Proficient user in Microsoft Office Suite, specifically Excel, PowerPoint, Access, and Word.  A desire to expand those capabilities is required, as is the ability to train others to use such tools.

• Commitment to producing high quality analysis and attention to detail.

• Excellent time management, organizational skills, and ability to prioritize work and meet deadlines.

• Keen interest in healthcare compliance and healthcare policy.

• Exceptional verbal and written communication skills.

• Desire to work within a team environment.

Candidate must be able to submit verification of their legal right to work in the U.S., without company sponsorship.

Consultant Salary Range: $70,000 – $150,000

Managing Consultant Salary Range: $100,000 – $230,000

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