Sr Billing Compliance Auditor

Nicklaus Children's Hospital•Miami, FL

About The Position

The Sr Billing Compliance Auditor serves as the liaison responsible for monitoring and auditing NCPS coding and documentation functions for professional fee services. Conducts independent ongoing reviews of vendor and provider-coded professional fee services to ensure practices meet federal requirements. Works closely with NCPS to communicate monitoring / auditing results and provide feedback to support necessary actions taken accordingly. Functions as the subject matter expert for professional fee coding and documentation, and partners with NCPS administrators to ensure consistent, compliant, and accurate coding practices.

Requirements

Certified Coder Certified Professional Coder (CPC) and/or Certified Coding Specialist – Physician
7-10 years of experience with physician (professional fee) billing, coding, documentation and compliance.
7-10 years of experience interpreting complex regulatory guidelines, relaying applicability of such, and engaging with senior leaders.
7-10 years experience with proficiency in coding physician practice and surgical procedures.
7-10 years years of experience leading and executing internal audits, analyzing the findings and developing, implementing, and monitoring the corrective action plan(s).

Nice To Haves

Bachelor's Degree or Associate Degree, preferred.
Strong communication skills.
The ability to work independently, demonstrates high-level autonomy and is proactive.
Ability to communicate clearly and courteously (verbal and written) with internal and external customers.
Good organizational skills and adaptability to frequent changes in assignments.
General knowledge of revenue cycle and pediatric industry experience.
Maintain active membership in national association(s) with required CEU credits.
PowerPoint and reporting proficient.
Knowledge of managed care regulations regarding patient type criteria and appropriateness of patient type statuses by healthcare professionals when admitting patients as OP, OBS, or IPs.
Outstanding analytical and organization skills with attention to detail.
Demonstrable problem solving skills.
Ability to maintain confidentiality of sensitive information.
Ability to interface with compliance and outside auditors.
Create, develop and give presentations.

Responsibilities

Conducts audits of NCPS professional fee encounters to validate accuracy of CPT, HCPCS, ICD‑10‑CM, and modifier assignment.
Serves as the coding, documentation, and billing expert for NCPS, ensuring focused expertise on pediatric, Fl AHCA / Medicaid, and CMS regulatory requirements.
Monitors professional fee vendor-coding services to ensure alignment with CMS and Florida Medicaid (AHCA) coding, documentation and billing requirements.
Verifies that documentation meets regulatory and organizational standards for medical necessity, specificity, and completeness.
Adheres to monitoring and audit plans, including routine, focused, and prospective audits.
Collaborates closely with NCPS assigned liason(s) / administrators to ensure timely and effective communication of findings and recommendations for next steps.
Prepares trends, errors rates, and recommendations for correct action.
Fosters a collaborative, solutions‑focused relationship with coding and billing vendor(s), ensuring a culture of transparency, continuous quality improvement, and shared commitment to accurate, compliant coding practices.
Analyzes monitoring and auditing data to identify patterns, recurring issues, and opportunities for improvement.
Acts as a resource to NCPS administrators regarding coding and documentation processes.
Maintains current knowledge of CMS, AMA, and AHCA coding, documentation and billing guidelines. Prepares updates of changes to provide to NCPS administrators.
Researches, analyzes and provides guidance on compliance and coding concerns.
Maintains open communication with NCPS administrators and Epic team(s) for any changes or updates to the system that can impact or improve activity of auditors and coding, documentation, and billing processes.