Compliance Auditor

Mental Health Cooperative•Nashville, TN

21h•Onsite

About The Position

The Compliance Auditor is responsible for conducting compliance auditing, monitoring, and risk assessment activities to ensure organizational adherence to federal, state, accreditation, contractual, and organizational requirements. This position evaluates clinical, billing, operational, and administrative functions to ensure compliance with regulations and standards established by the Office of Inspector General (OIG), Centers for Medicare & Medicaid Services (CMS), The Joint Commission (TJC), Tennessee Department of Mental Health and Substance Abuse Services (TDMHSAS), Managed Care Organizations (MCOs), and other applicable regulatory authorities. The Compliance Auditor identifies areas of regulatory risk, recommends corrective actions, evaluates the effectiveness of compliance controls, and supports continuous improvement efforts throughout the organization.

Requirements

Bachelor's degree in Healthcare Administration, Public Health, Business Administration, Nursing, Social Work, Behavioral Health, Accounting, or related field required.
Minimum of three (3) years of healthcare auditing, compliance, quality improvement, revenue cycle, or regulatory experience required.
Extensive knowledge of OIG Compliance Program Guidance, CMS regulations, Medicaid and TennCare requirements, TJC accreditation standards, TDMHSAS rules and regulations, MCO contractual requirements, HIPAA Privacy and Security Rules, and Fraud, Waste, and Abuse prevention practices.
Medical record review and auditing skills.
Data analysis and trend identification skills.
Audit report writing skills.
Risk assessment methodologies.
Root cause analysis skills.
Corrective action plan development skills.
Proficiency with EHR systems and Microsoft Office applications.
Strong analytical and critical thinking abilities.
Excellent verbal and written communication skills.
High attention to detail.
Ability to maintain confidentiality.
Strong organizational and time-management skills.
Ability to work independently and collaboratively.
Ability to travel between organizational sites as needed.
Ability to sit for extended periods while reviewing records and data.
Ability to access and review electronic health records and paper documentation.
Will require participation in regulatory surveys, audits, accreditation reviews, and compliance investigations.
Must maintain confidentiality and handle sensitive information appropriately.

Nice To Haves

Master's degree preferred.
Experience in behavioral health, community mental health, substance use treatment, or healthcare settings strongly preferred.
Experience auditing Medicaid-funded services preferred.
Certified in Healthcare Compliance (CHC)
Certified Professional Medical Auditor (CPMA)
Certified Internal Auditor (CIA)
Certified Professional Coder (CPC)
Certified Healthcare Internal Audit Professional (CHIAP)

Responsibilities

Conduct routine and focused audits of clinical documentation, medical records, billing, coding, claims submission, service authorization, and operational processes.
Perform audits to ensure compliance with CMS, Medicaid, TennCare, TDMHSAS, TJC, OIG, and MCO requirements.
Evaluate documentation for medical necessity, treatment planning, service delivery, timeliness, and completeness.
Review provider credentialing and licensure compliance.
Assess adherence to organizational policies and procedures.
Develop audit work plans, audit tools, and monitoring methodologies.
Maintain audit schedules and ensure completion of annual compliance audit plans.
Identify regulatory, operational, financial, and compliance risks across the organization.
Analyze audit findings to identify trends, root causes, and systemic issues.
Assist with annual compliance risk assessments.
Evaluate internal controls and compliance processes for effectiveness.
Recommend risk mitigation strategies and process improvements.
Prepare written audit reports detailing findings, observations, risks, and recommendations.
Collaborate with department leaders to develop corrective action plans.
Monitor implementation of corrective actions and validate effectiveness.
Conduct follow-up audits to ensure sustained compliance.
Track audit findings and compliance metrics.
Monitor changes in federal and state healthcare regulations affecting behavioral health services.
Ensure compliance with OIG Compliance Program Guidance, CMS Medicaid and Medicare regulations, TJC accreditation standards, TDMHSAS licensing and contractual requirements, TennCare regulations, Managed Care Organization (MCO) contracts and policies, HIPAA Privacy and Security Rules, and Fraud, Waste, and Abuse regulations.
Assist departments in preparing for regulatory reviews, accreditation surveys, external audits, and site visits.
Participate in mock surveys and readiness assessments.
Review evidence and documentation requested by surveyors and auditors.
Support remediation activities resulting from external audits.
Maintain complete and accurate audit documentation and work papers.
Prepare reports for the Compliance Committee, Executive Leadership Team, and Board of Directors.
Track key audit indicators and organizational compliance trends.
Utilize compliance management software, spreadsheets, and reporting tools to monitor audit outcomes.
Provide guidance to operational and clinical staff regarding compliance requirements.
Educate departments on audit findings and regulatory expectations.
Assist with compliance training and awareness initiatives.
Serve as a compliance resource for managers and leadership.