Compliance Auditor RCM

Job Summary

The Compliance RCM Auditor is responsible for reviewing and verifying that a healthcare provider's revenue cycle management (RCM) practices adhere to all relevant compliance regulations, including coding guidelines, billing procedures, and patient demographic data, by conducting audits to identify potential issues and ensure accurate billing and patient record keeping, while recommending corrective actions to maintain compliance with federal and state laws.

The Compliance RCM Auditor works independently performing program, compliance, and risk-based reviews of health care related activities to ensure accuracy of related medical record documentation, coding, billing and policies. Provides written audit summary of findings to include audit recommendations. Conducts revenue cycle investigations to determine and mitigate risk through findings, reports, and recommended actions

Summary Of Essential Job Functions

The key responsibilities of the Compliance RCM Auditor include but not limited to:

• Reviewing medical records: Analyzing patient charts to ensure proper diagnosis and procedure coding (CPT, ICD-10, HCPCS) accuracy against billing claims.
• Claims auditing: Assessing submitted claims for compliance with payer contracts, including verifying patient demographics, insurance eligibility, and billing codes.
• Data analysis: Utilizing data analytics tools to identify patterns of potential compliance issues, such as high denial rates or unusual coding trends.
• Contract compliance: Reviewing payer contracts to ensure accurate billing practices and appropriate reimbursement based on contract terms.
• Documentation review: Checking for complete and accurate documentation supporting medical necessity for billed services.
• Identifying areas for improvement: Reporting findings and providing recommendations to improve RCM processes and mitigate compliance risks.
• Investigating complaints: Reviewing potential compliance concerns raised by patients, payers, or internal stakeholders.
• Reporting and documentation: Preparing detailed audit reports with findings, corrective action plans, and supporting documentation.
• Responsible for complying with all federal, state and local regulatory agency requirements
• Responsible for complying with all accrediting agencies
  
  

Qualifications

• Compliance Auditing experience required, preferred experience in behavioral health and/or substance abuse auditing
• Proven expertise in healthcare coding, preferably within mental and behavioral health, or substance abuse strongly preferred.
• Thorough understanding of medical coding systems (CPT, ICD-10, HCPCS) and their application in clinical practice.
• Deep familiarity with HIPAA, Medicare, Medicaid, and other relevant healthcare compliance laws
• Proven experience conducting RCM audits, including sample selection, data analysis, and report writing
• Ability to analyze complex data, identify trends, and draw accurate conclusions
• Certified Professional Coder (CPC) and/or Certified Professional Medical Auditor (CPMA) or CIA strongly preferred. If not certified, willing to pursue certification.
• Meticulous approach to reviewing medical records and billing data to ensure accuracy
• Effective communication with healthcare providers, billing staff, and management to discuss audit findings and recommendations
• The Compliance RCM Auditor must comply with federal and state regulations regarding certification, licensure, and degree.