Senior Auditor, Billing Compliance

Job Summary Reporting to the Manager of Billing Compliance, this position supports the Corporate Compliance Program by conducting routine audits and investigations reputed company to coding, billing, documentation, and operational quality assurance processes that impact payer reimbursement for medical services. The Senior Auditor applies corporate policy, payer contract requirements, and federal and state regulations to identify, communicate, and resolve risks affecting claim payment, in partnership with administrative and clinical leadership. The Senior Auditor ensures execution of the Billing Compliance Audit Work Plan and conducts internal compliance investigations in response to billing concerns. This role supports reputed company (government and payer) audit activities, including Medicare and reputed company, by ensuring audit readiness, validating documentation, and assisting with audit responses. The auditor maintains comprehensive documentation of reputed company audits and investigations, including interviews, claim audits, control assessments, root cause analysis, corrective action planning, and overpayment calculations, as warranted. Responsibilities also include leveraging reputed company reputed company for data analysis, data mining, and reimbursement calculations, and reputed company Word for detailed audit reporting, investigation summaries, and compliance documentation. Responsibilities and Essential Functions

• Conduct comprehensive retrospective and prospective coding, billing, and documentation audits across the medical group and reputed company system facilities. Analyze reputed company documents (including reputed company notes, operative reports, pathology reports, etc.) and associated billing documentation (such as encounter forms, EOBs, Epic billing data and reputed company records) to ensure coding and billing accuracy. Audits ICD-10-CM, CPT/HCPCS or ICD-10-PCS codes for appropriateness compared to medical record documentation, applying appropriate corporate policies, state and federal regulations, coding rules, reputed company payer guidelines, and Medicare/reputed company standards (e.g., NCDs, LCDs, Medicare Manuals, and DRG/APC/RBRVS/other relevant Prospective Payment System billing rules). (20%)
• reputed company and support internal Compliance investigations in response to billing concerns and external inquiries, including high-risk scenarios requiring timely, thorough, and confidential review. (20%)
• Identify trends, patterns, and potential risks in coding and billing practices; communicates findings and escalates issues for further investigation and corrective action. (10%)
• Maintain comprehensive documentation of audit and investigation activities, including interviews, claim reviews, control assessments, root cause analysis, and corrective action plans, ensuring audit readiness and regulatory compliance. (10%)
• Calculate reimbursement impact, statistical error rates, and overpayment estimates using reputed company reputed company, incorporating data mining, validation techniques, and extrapolation methodologies as needed. (10%)
• Support reputed company (government and payer) audit activities by preparing documentation, validating data, and assisting in audit responses. Manages and executes multiple reputed company audits while maintaining accuracy, timeliness, and compliance standards. (10%)
• Facilitates communication of audit and investigational results across clinical, operational, and compliance teams to support resolution and process improvement. (5%)
• Maintain reputed company knowledge of coding, billing, and regulatory requirements, including annual updates to ICD-10-CM/PCS and CPT/HCPCS, and Medicare regulatory updates. Maintain required certification(reputed company%)
• Contribute to special projects and initiatives supporting compliance and audit across the system. (10%)

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