Healthcare Coding Compliance Auditor - RUHS

DaMar Staffing; Riverside (CA); Hybrid; USD 90,000 - 130,000; Full time

Job summary

Riverside University Health System (RUHS) seeks two Coding Compliance Auditors to support its Compliance Department. The role involves reviewing medical records for coding accuracy, performing DRG-related audits, and educating staff on regulatory changes.

Ideal candidates have 5+ years in acute care settings with MS-DRG reimbursement, 3–5 years in coding audit, and CCS/CPC/RHIT/C DIP/CPMA-style credentials. Hybrid schedule in Riverside, CA.

Qualifications

• Five+ years in an acute care hospital setting with inpatient MS-DRG reimbursement.
• 3–5 years of coding audit or compliance auditing experience.
• Strong knowledge of CMS IPPS/OPPS, OIG Work Plan priorities, and physician documentation rules.

Responsibilities

• Conduct comprehensive audits of inpatient and outpatient records for ICD-10-CM/PCS, CPT, and HCPCS coding.
• Evaluate DRG assignments, diagnoses, procedures, CC/MCC capture, and POA indicators.
• Monitor compliance with Medicare, Medicaid, and payer policies.
• Identify risks related to medical necessity, upcoding, undercoding, and unbundling.
• Prepare audit reports with findings, root cause, and corrective actions.

Skills

MS-DRG reimbursement

Auditing experience

Regulatory knowledge

Communication skills

Education

Bachelor's degree in accounting, business, or public administration, information services, finance, or related field

Tools

3M Encoder

Optum Encoder

EPIC

Job description

Coding Compliance Auditor

Riverside University Health System (RUHS) is seeking two skilled Coding Compliance Auditors (Administrative Services Manager I) to support the Health System's Compliance Department.

Key Responsibilities

• Key responsibilities of this role include conducting thorough reviews of medical records to ensure compliance with coding regulations, while providing feedback and education to coders and physicians to enhance coding accuracy and documentation quality.
• The position involves performing annual, periodic, and focused audits of physician, inpatient, and outpatient coding as requested.
• It also requires effective communication with all RAC stakeholders to ensure timely and accurate responses to inquiries.
• Additionally, the role supports ongoing program development through training initiatives and process improvements, delivers coding presentations to diverse audiences including physicians and other staff.

Ideal Candidate

The ideal candidate will have at least five years of progressive experience in an acute care hospital setting, including inpatient MS-DRG reimbursement, along with 3–5 years of coding audit or compliance auditing experience.

This includes extensive expertise in inpatient and outpatient auditing (MS-DRGs, CC/MCC validation, POA indicators, PSI/HAC implications), managing external audits (RAC, MAC, OIG, UPIC, commercial payers), and strong knowledge of CMS IPPS/OPPS regulations, OIG Work Plan priorities, Medicare Conditions of Participation, Official Coding Guidelines, NCCI edits, and medical necessity rules.

The candidate should have experience conducting risk assessments, developing audit work plans, quantifying financial impact, presenting findings to leadership, collaborating across CDI, HIM, Revenue Integrity, and Compliance teams, providing provider education, and supporting denials and appeals.

Experience in large or multi‑facility health systems, proficiency with encoder and audit software (e.g., 3M, Optum, EPIC) is strongly preferred.

Two years of supervisory experience is required as well as one of the following certifications: CCS, CPC, RHIT/RHIA, CDIP, or CPMA.

Schedule and Location

• Schedule: 9/80 work schedule - hybrid
• Location: 7898 Mission Grove Parkway, Riverside

Performance Recognition

This class has been deemed eligible for the Performance Recognition Plan as set forth under Article 3, Section 311 of the County Management Resolution. Program eligibility requires employees to be in a leadership position, manage other employees or programs and have significant influence on the achievement of organizational objectives.

About RUHS Medical Center

Every day at Riverside University Health System Medical Center, a dedicated team of healthcare professionals and support staff come together to improve lives across Riverside County. Our nationally recognized programs and specialized services thrive because of the diverse talents and commitment of our team members. No matter your background or skill set, you'll discover meaningful opportunities and a strong sense of purpose here.

To learn more about RUHS Medical Center, please visit www.ruhealth.org

Audit Responsibilities

• Conduct comprehensive audits of inpatient and outpatient medical records to ensure accurate ICD-10-CM/PCS, CPT, and HCPCS coding in accordance with official coding guidelines and regulatory requirements.
• Evaluate DRG assignment accuracy and validate principal and secondary diagnoses, procedures, CC/MCC capture, and POA indicators.
• Monitor compliance with federal and state regulations, including Medicare, Medicaid, and commercial payer policies.
• Assess adherence to documentation standards and identify risk areas related to medical necessity, upcoding, undercoding, and unbundling.
• Perform focused audits based on risk assessments, OIG Work Plan priorities, denials trends, and internal compliance initiatives.
• Collaborate with Clinical Documentation Integrity (CDI), Health Information Management (HIM), Revenue Cycle, and Case Management teams to resolve coding discrepancies and improve documentation quality.
• Prepare detailed audit reports outlining findings, root cause analysis, financial impact, and corrective action recommendations.
• Educate providers, coders, and revenue cycle staff on regulatory updates, coding changes, audit findings, and compliance risks.
• Track audit metrics, monitor corrective action plans, and perform re-audits to ensure sustained compliance improvements.
• Support internal investigations and respond to external audit requests (RAC, MAC, OIG, commercial payers).
• Maintain knowledge of CMS transmittals, coding clinic updates, and evolving regulatory guidance affecting acute care services.
• Contribute to enterprise-wide compliance risk assessments and annual compliance work plan development.

Education

Graduation from an accredited college or university with a bachelor's degree, preferably with a major in accounting, business or public administration, information services, finance, or a closely related field to the assignment. (Additional qualifying experience may be substituted for the required education on the basis of one year of full-time experience equaling 30 semester or 45 quarter units of the required education.)

Experience

Minimum of three years experience in an administrative or staff capacity which must have included at least two years of experience supervising professional and technical staff in two of the following areas: gathering and compiling facts and statistics to evaluate program effectiveness and recommend program revisions; preparing and maintaining a program budget or maintaining and controlling the fiscal record keeping functions and systems in a department, agency, division, unit or company; coordinating and conducting studies of administrative and operational activities including budget preparation and control, equipment usage, staff patterns, work flow and space utilization. (Possession of a Master's degree from an accredited college or university in accounting, business or public administration, finance, or a closely related field may substitute for up to two years of the required experience on the basis of 30 semester or 45 quarter units equaling one year of full-time experience.)

Certifications (required)

• Certified Coding Specialist (CCS)
• Certified Professional Coder (CPC)
• Registered Health Information Tech/Administrator (RHIT/RHIA)
• Certified Document Integrity Practitioner (CDIP)
• Certified Professional Medical Auditor (CPMA)