Compliance Auditor - Billing

Jefferson Health Plans•Philadelphia, PA

1d•Remote

About The Position

Under general supervision, performs risk-based audits of clinical documentation, coding, and billing records to ensure that documentation supports services billed and complies with applicable regulatory and organizational requirements. This position independently validates documentation and coding compliance, identifies areas of compliance risk, and supports internal audit activities and external audit readiness across hospital-and provider-based settings. This role is outcome-driven and requires the ability to independently manage audit workload, documentation, and deadlines.

Requirements

Bachelor’s Degree in Health information management, Healthcare Administration, or related field, or equivalent experience.
3 years of progressive experience in coding, and or regulatory compliance auditing in a healthcare setting.
Strong knowledge of federal and state laws, third party payer regulations, and documentation and coding requirements.
Demonstrated ability to perform independent, defensible audit analysis and communicate findings effectively to clinical and operational stakeholders.
Strong organizational, problem-solving, and communication skills, with the ability to manage multiple priorities and deadlines in a complex environment.
Experience working in Epic or similar electronic health record systems.
Proven ability to manage change and work effectively in changing regulatory environments.
Strong knowledge of federal and state laws, third-party payer regulations, and documentation and coding requirements.
Strong communication and interpersonal skills with a high degree of professionalism when engaging with clinicians, coding professionals, and operational stakeholders.
Effective problem-solving skills, with the ability to perform independent, defensible audit analysis.
CPC - Certified Professional Coder - American Academy of Professional Coders Upon Hire or CCS-P - Certified Coding Specialist-Physician Based - American Health Information Management Association Upon Hire or RHIA - Registered Health Information Administrator - American Health Information Management Association Upon Hire or RHIT - Registered Health Information Technician - American Health Information Management Association Upon Hire or CIC - Certified Inpatient Code - American Academy of Professional Coders Upon Hire or COC - Certified Outpatient Coder - American Academy of Professional Coders Upon Hire

Nice To Haves

Experience performing provider-side and hospital-based documentation and coding audits strongly preferred.
CRC - Certified Risk Adjustment Coder - American Academy of Professional Coders Upon Hire or CHC - Certified Healthcare Compliance - Compliance Certification Board Upon Hire

Responsibilities

Performs risk-based audits of clinical documentation, physician, technical, and specialty billing and payment records by analyzing medical records, coding records, and health system bills to validate that documentation supports services billed and complies with applicable regulations and guidelines.
Evaluates the accuracy and appropriateness of coding, billing, and documentation practices, including assessment of medical necessity, level of service, and adherence to federal, state, and payer specific requirements.
Conducts audits across professional fee, hospital, and specialty services, including inpatient, outpatient, procedural, and ancillary services, as applicable.
Identifies patterns, trends, and outliers in documentation and coding practices and escalates identified compliance risks through appropriate compliance governance channels.
Utilizes audit findings, internal data, and regulatory focus areas to support the development and execution of risk-based audit plans aligned with organizational priorities.
Supports responses to external audit requests (e.g., government, payer, and regulatory reviews) through documentation review, validation, and compliance risk assessment.
Conducts targeted internal reviews in response to external audit findings or identified areas of compliance risk.
Maintains complete, accurate, and defensible audit workpapers supporting audit conclusions and quality assurance review.
Prepares clear, concise audit reports summarizing findings, risk areas, and recommendations for Compliance leadership and stakeholders.
Works collaboratively with appropriate personnel, including Revenue Cycle, Coding, and operational teams, to support compliance objectives while maintaining independent audit judgment.
Communicates audit findings and identified risk area to appropriate stakeholders to support follow-up activities led by designated education or operational teams.
Develops and maintains audit tools, methodologies, and workflows to support consistent and effective audit execution. Identifies opportunities for process improvement related to internal auditing and compliance monitoring activities.