Join the transformative team at City of Hope, where we're changing lives and making a real difference in the fight against cancer, diabetes, and other life-threatening illnesses. City of Hope’s growing national system includes its Los Angeles campus, a network of clinical care locations across Southern California, a new cancer center in Orange County, California, and treatment facilities in Atlanta, Chicago and Phoenix. our dedicated and compassionate employees are driven by a common mission: To deliver the cures of tomorrow to the people who need them today. 

As a successful candidate, you will: 

The Senior Provider Compliance Auditor serves as an institutional subject matter expert and authoritative resource on interpretation and application of documentation and coding rules and regulations, and medical necessity of services delivered. This role evaluates the adequacy and effectiveness of controls designed to ensure that processes and practices lead to appropriate execution of regulatory requirements and guidelines related to professional documentation, coding and billing, including federal and state regulations and guidelines, CMS and other third-party payor billing rules, and OIG compliance standards.

Duties & Responsibilities- 

• Responsible for the documentation and evidencing an effective Corporate Compliance Program consistent      with professional standards  

• Plans and performs scheduled and unscheduled compliance professional claims audits, including accuracy and  adequacy of documentation and coding related to physician (inpatient and outpatient) billing and/or medical  necessity reviews.  

• Evaluates appropriateness of ICD, HCPCS and CPT, codes billed.  

• Partner with departmental management with the development of documentation and coding tools and templates  and makes recommendation, coding, and billing process improvement.

• Prepares written reports of audit findings and recommendations and presents to appropriate stakeholders;  evaluates the adequacy of management corrective action to improve deficiencies; maintains audit records.

• Acts as a liaison with assigned faculty members, developing relationships and functioning as a resource to all providers and their staff.

• Collaborates with department management on any compliance investigations related to documentation and coding of professional claims and assists with corrective action plans.

    

• Stays current with Medicare, Medicaid and other third party rules and regulations, CPT, ICD10 coding updates.

Your qualifications should include:  

Minimum Education:

Bachelor's Degree; 3 additional years of experience plus the minimum experience requirement may substitute for minimum education.

Five (5) years of E/M coding/auditing experience. 

Minimum Experience:

Extensive knowledge of evaluation and management coding and auditing is required.

Knowledge of medical terminology; E/M rules, teaching physician guidelines, and/or medical necessity defense reviews; healthcare compliance audit methodology, principles, and techniques; CMS manuals; professional reimbursement and repayment; confidentiality standards. Knowledge of federal, state, and payer-specific regulations and policies pertaining to documentation, coding, and billing, with demonstrated ability to interpret such guidelines

Required Courses/Training:

Must possess a Certified Professional Coder (CPC) or Certified Coding Specialist Certificate, Physician Based (CCS-P), Certified Professional Medical Auditor (CPMA) and/or AAPC or AHIMA recognized coding certification.