Compliance Auditor – OP-Ambulatory Services

Baptist Health Care • Pensacola, FL

1d

About The Position

This entry-level position audits outpatient and professional services claims submitted to federally funded healthcare payors across the Baptist Physician Enterprise (BPE). It analyzes coded records for accuracy and compliance with federal, state, and third-party insurer rules and regulations, as well as applicable coding guidelines. The role provides Operations and staff with guidance on error trends and ways to prevent or reduce errors, supporting compliance with the False Claims Act, the Federal Overpayment Rule, and CMS and Medicaid billing and coding requirements. It calls for attention to detail, strong communication and critical-thinking skills, and a commitment to high ethical standards.

The auditor performs routine and targeted audits, reviews clinical documentation and coding, documents audit findings, and shares recommendations with providers and department leaders. The position also educates healthcare staff on documentation requirements, coding practices, and relevant regulatory or guideline changes, and identifies claims requiring correction or other reimbursement-related remedies.

Requirements

• Bachelor's degree in Health Information Management or a related field, or four years of related experience in lieu of a bachelor's degree.
• Five years of experience in a healthcare provider environment.

Nice To Haves

• One year of healthcare coding and billing experience.
• Zero to one year of experience with Healthicity, electronic health records such as Altera Sunrise or Epic, Hyland MRM, Clintegrity, FinThrive, and the MS Office Suite, particularly Excel.

Responsibilities

• Perform routine and targeted audits of patient services and corresponding claims submitted to government payors.
• Audit outpatient and professional service records and claims for adherence to corporate policy and accuracy standards, and recommend corrective action, education, or training as needed.
• Audit the assignment of ICD-10-CM diagnostic codes, ICD-10-PCS procedural codes, CPT codes with modifiers, and other applicable codes on sampled outpatient and ambulatory cases.
• Review, analyze, and abstract physician and other documentation for diagnoses, procedures, ancillary testing, medications, laboratory services, and other services provided.
• Use Healthicity or other compliance and audit systems, and develop and maintain comprehensive audit reports and documentation of audits, sampled cases, and findings.
• Meet with audited providers and department leadership to present audit findings and recommendations.
• Educate Operations regarding performance patterns in audited records.
• Inform physicians and other healthcare staff about documentation requirements, current coding practices, and changes in state and federal regulations and guidelines relevant to audits.
• Participate in and provide education sessions on specific coding topics at huddle meetings and other forums, as directed.
• Communicate with physicians and other healthcare staff to locate documentation or clarify existing information.
• Identify claims requiring correction or other reimbursement-related remedies to address coding and billing errors found through audit activities.
• Maintain operational excellence and deliver quality audit services in accordance with applicable policies, procedures, and professional standards.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level