Audit Defense Auditor

CareCloud · Somerset, United States

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

This job is responsible for the successful delivery of detailed and complex medical record reviews for Audit Defense and Regulatory Audits. The incumbent is responsible for interface with clients and staff. The incumbent is responsible for completion of coding audits review of medical records and coding for appropriate interpretation and designations including chart documentation review, ICD10 and CPT coding audit, and creating detail oriented, appropriate findings report for the client. Ensure compliance with required Regulatory Audit guidelines are being met with regards to coding and documentation.

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

Role/location

This is a full-time position for a Certified Coder/Auditor Audit Defense, based in either of our offices. Somerset, NJ or Fort Lauderdale, FL. Requires hybrid on-site at either location.

The primary responsibilities include conducting detailed audits, ensuring compliance with healthcare regulations, and performing accurate medical coding. Additional tasks involve working closely with healthcare providers to review documentation, resolve coding discrepancies, and ensure adherence to the relevant standards and best practices in coding and auditing.

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