Healthcare Audit Defense Auditor-Coder

CareCloud; New Jersey; On-site; USD 75,000 - 110,000; Full time

Job summary

Empower Healthcare and Compliance Partners, a subsidiary of CareCloud, seeks an experienced Audit Defense Auditor/Coder in New Jersey to lead regulatory audits for coding teams and ensure compliance with CMS and payer guidelines. The role requires strong clinical documentation knowledge and coding expertise.

You will mentor audit teams, prepare final reports, and assist with appeals of regulatory determinations, collaborating with Compliance and Legal to improve provider documentation and coding

Qualifications

• Background dealing with payor audits, legal defenses, appeals/denials.
• Proficiency in Medical Coding and strong knowledge of Medical Terminology.
• Experience with Coding Standards and familiarity with Health Information Management principles.
• CPC certification or equivalent credentials.
• Bachelor’s degree in a related field or relevant work experience is preferred.

Responsibilities

• Lead regulatory audits for coding teams.
• Ensure completion of projects to meet regulatory / departmental deadlines.
• Provide business and/or subject matter expertise for regulatory audits.
• Communicate and collaborate with management to assemble, and mentor, audit coding team(s) to ensure deliverables are met or exceeded.
• Ensure audit compliance with CMS Coding Guidelines and Payer Coding Guidelines.
• Review and analyze weekly reports to ensure appropriate quality review performance and results.
• Prepare final audit reports per exact specifications for Audit Defense or Client Audit.
• Assist Legal with Appeals of Regulatory Audit final determinations. Interface with Compliance and Legal regarding Appeals of Regulatory Audit final determinations.
• Conduct data analyses from medical record reviews to identify opportunities to improve provider documentation and coding.
• Interface with client revenue programs for provider education teams to identify educational opportunities for targeted providers. Identify and collaborate in developing process improvement initiatives.
• Participate in all Regulatory Audit training, monitor publications from regulatory agencies, to make updates to current processes ensure audit coding compliance.
• Other duties as assigned or requested.

Skills

Regulatory audits

Medical coding

CMS guidelines

Payer audits

Analytical skills

Communication

Education

Associate degree in healthcare

Job description

Empower Healthcare and Compliance Partners (Empower HCP) (subsidiary of CareCloud) is a leading healthcare compliance and networking firm dedicated to equipping providers and systems with the necessary tools, resources, and expertise to navigate the ever-changing regulatory landscape. We understand that compliance is the foundation of providing safe, ethical, and high-quality care to patients. Our mission is to empower healthcare organizations to meet compliance standards effectively, fostering better outcomes and trustworthy services in the healthcare industry.

Audit Defense Auditor/Coder

Background dealing with payor audits, legal defenses, appeals/denials

ESSENTIAL RESPONSIBILITIES

Background dealing with payor audits, legal defenses, appeals/denials

Coder Certification required

• Lead regulatory audits for coding teams.
• Ensure completion of projects to meet regulatory / departmental deadlines.
• Provide business and/or subject matter expertise for regulatory audits.
• Communicate and collaborate with management to assemble, and mentor, audit coding team(s) to ensure deliverables are met or exceeded.
• Ensure audit compliance with CMS Coding Guidelines and Payer Coding Guidelines.
• Review and analyze weekly reports to ensure appropriate quality review performance and results.
• Prepare final audit reports per exact specifications for Audit Defense or Client Audit.
• Assist Legal with Appeals of Regulatory Audit final determinations. Interface with Compliance and Legal regarding Appeals of Regulatory Audit final determinations.
• Conduct data analyses from medical record reviews to identify opportunities to improve provider documentation and coding.
• Interface with client revenue programs for provider education teams to identify educational opportunities for targeted providers. Identify and collaborate in developing process improvement initiatives.
• Participate in all Regulatory Audit training, monitor publications from regulatory agencies, to make updates to current processes ensure audit coding compliance.
• Other duties as assigned or requested.

EDUCATION

Minimum Required Associate’s degree in healthcare, Clinical or Business Related

EXPERIENCE

5 years’ experience with clinical documentation auditing and a minimum of 1 year in audit defense or

(3 ) years of experience providing defensive support for CMS and payer audits through comprehensive chart reviews, coding validation, findings report preparation, and appeal support in accordance with regulatory guidelines or

(3 ) years of experience of payer‑side audit experience including medical record review, coding validation, and CMS guideline application.

Preferred

5 years of Coding Project Management

To Include:

3 years of monitoring, evaluating audit progress, reporting and work prioritization within cross functional teams

CERTIFICATIONS

Required

Certified Coding Specialist (CCS)/Certified Professional Coder (CPC) or

Certified Paralegal

Qualifications

Background dealing with payor audits, legal defenses, appeals/denials

Proficiency in Medical Coding and strong knowledge of Medical Terminology

Experience with Coding Standards and familiarity with Health Information Management principles

CPC certification or equivalent credentials

Strong analytical skills with the ability to conduct detailed audits

Excellent communication and collaboration skills for working with diverse teams

Bachelor’s degree in a related field or relevant work experience is preferred

Familiarity with healthcare compliance guidelines and regulations is a plus

Industry

Hospitals and Health Care