Compliance Auditor

Lexington Health; West Columbia (SC); On-site; USD 80,000 - 110,000; Full time

Benefits offered by this job

Day ONE medical, dental and life

403(b) plan day one match

Employer paid life insurance

Short/long-term disability after 90d

Employee loan forgiveness

Job summary

Lexington Health is seeking a qualified auditor to analyze and audit the Physician Network and hospital medical records to ensure charges are supported by documentation and billed correctly. You will monitor risk areas, prepare reports, and present audit results to physicians and APPs.

The role requires a Bachelor’s Degree in Business or a related field and at least 3 years of directly related experience, with CMPA/CCS/CPC certifications encouraged.

Qualifications

• Bachelor’s Degree in Business or Related Field preferred.
• 3 years of directly related experience required.
• CPMA/CCS/CPC certifications encouraged; CPMA must be obtained within 1 year of entry.

Responsibilities

• Conduct audits of hospital and Physician Network records to ensure services are documented and billed correctly according to Medicare, Medicaid, and third-party regulations.
• Assist the Chief Compliance Officer in investigations related to erroneous billing and coding.
• Collaborate with Revenue Integrity and Health Information Management on reviews and inquiries.
• Draft formal written reports summarizing medical record findings for review.
• Educate LMC staff on coding and billing changes as needed.
• Verify Medicare/CMS criteria and local guidance are applied in reviews.

Skills

Communication

Problem solving

MS Office

Education

Bachelor’s Degree in Business or Related Field

High School Diploma with 7 years of related experience

Associate’s Degree with 5 years of related experience

Tools

Microsoft Office

Job description

Lexington Health is a comprehensive network of care that includes six community medical and urgent care centers, nearly 80 physician practices, more than 9,000 health care professionals and Lexington Medical Center, a 607-bed teaching hospital in West Columbia, South Carolina. It was selected by Modern Healthcare as one of the Best Places to Work in Healthcare and was first in the state to achieve Magnet with Distinction status for excellence in nursing care. Consistently ranked as best in the Columbia Metro area by U.S. News & World Report, Lexington Health delivers more than 4,000 babies each year, performs more than 34,000 surgeries annually and is the region's third largest employer.

Lexington Health also includes an accredited Cancer Center of Excellence, the state’s first HeartCARE Center, the largest skilled nursing facility in the Carolinas, and an Alzheimer’s care center. Its postgraduate medical education programs include family medicine and transitional year residencies, as well as an informatics fellowship.

Job Summary

Analyze and audit LMC systems of the Physician Network and the hospital medical record data to determine if charges billed are supported by appropriate medical documentation. Monitors risk areas and conducts focused audits as identified by the Compliance Audit Manager. Prepares reports and meets with physicians and Advanced Practice Providers (APPs) to review audit results.

Minimum Qualifications

Minimum Education: Bachelor’s Degree in Business or Related Field

Minimum Years of Experience: 3 Years of directly related experience

Substitutable Education & Experience (Optional): A Bachelors and 3 years of experience can be substituted for the following combinations of education/work experience:

High School Diploma with 7 years of directly related experience;

Associate’s Degree with 5 years of directly related experience.

Required Certifications/Licensure: Certified Professional Coder (CPC) Certification through AAPC or Certified Coding Specialist (CCS) through AHIMA;

Certified Professional Medical Auditor (CPMA) Certification (Not required at placement into the role, but must be obtained within 1 year of entry date).

Required Training: Strong problem solving skills;

Ability to articulate orally and in writing an understanding of complex issues and detailed action plans, while representing the organization professionally. Must be able to communicate with physicians, Advanced Practice Providers (APPs), senior administrators and department staff;

Proficient in Microsoft Office.

Essential Functions

• Responsible for conducting audits of hospital and Physician Network records to determine whether services provided to patients are appropriately documented and billed in accordance with Medicare, Medicaid, and third party billing regulations and/or standards.
• Assists the Chief Compliance Officer in investigating inquires which may relate to erroneous billing and coding of services.
• Works closely with other departments, Health Information Management and Revenue Integrity to conduct coding reviews and inquires.
• Drafts formal written reports that summarize medical record findings for review.
• Provides education on subjects pertinent to reviews conducted and any coding and billing changes to appropriate LMC staff.
• Determines whether medically necessary criteria are met as required by CMS and the fiscal intermediary through National Coverage Determinations (NDCs), Local Coverage Determinations (LCDs) and other guidance in effect at the time of the review.

Duties & Responsibilities

• Participates in risk assessment of areas of focus designated by the Recovery Audit Contractors, MIC, OIG, ZPIC and other regulatory agencies.
• Consults with the Revenue Integrity personnel and the Compliance Audit Manager when relevant issues of federal and state health care billing law and regulations are discovered to create overpayments.
• Keeps abreast of ICD-10, CPT-4, and HCPCS coding changes, compliance issues and regulations and provides communication and updates regarding changes in regulations, policies or procedures pertaining to the Compliance Program.
• Treats patients, fellow employees and all individuals met while representing the organization with courtesy and respect in keeping with the LMC vision.
• Adheres to organization wide policies.
• Performs all other duties as assigned.

We are committed to offering quality, cost-effective benefits choices for our benefit eligible employees and their families:

• Day ONE medical, dental and life insurance benefits
• Health care and dependent care flexible spending accounts (FSAs)
• Employees are eligible for enrollment into the 403(b) match plan day one. LHI matches dollar for dollar up to 6%.
• Employer paid life insurance – equal to 1x salary
• Employee may elect supplemental life insurance with low cost premiums up to 3x salary
• Adoption assistance
• LHI provides its full-time employees employer paid short-term disability and long-term disability coverage after 90 days of eligible employment
• Student loan forgiveness

Equal Opportunity Employer

It is the policy of Lexington Health to provide equal opportunity of employment for all individuals, and to remain compliant with applicable state and federal laws and regulations. Lexington Health strives to provide a discrimination-free environment, and to recruit, select, on-board, and employ all employees without regard to race, color, religion, sex, age, disability, national origin, veteran status, or pregnancy, childbirth, or related medical conditions, including but not limited to, lactation. Lexington Health endeavors to upgrade and promote employees from within the hospital where possible and consistent with the employee’s desires and abilities and the hospital’s needs.