Role Description Reporting to the VP of Compliance, the Compliance Auditor is responsible for ongoing analysis and review of coding accuracy, medical necessity documentation, and regulatory compliance in patient records. - Conduct compliance focused monitoring and audits related to coding accuracy, medical necessity, supporting documentation and other operational functions. - Conducts ad hoc reviews and audits based on high risk, problem prone, or otherwise specified areas. - Maintains tools, reports, data, metrics, benchmarking, tracking, and trending patient and compliance data. - Participates in various committees to address risks and opportunities for improvement, to report on compliance data, and collaborate in process improvement initiatives. - Provide reports to management on compliance metrics and audit findings as requested. Qualifications - RN or LPN required - Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) strongly preferred. - A minimum of three to five years experience in Medicare, Medicare Advantage, and/or Commercial Payers preferred. - Strong knowledge of Florida statutes, Medicare & Medicaid conditions of participation and payment, and commercial payer guidelines preferred. Requirements - Ability to accurately interpret regulations, payment and coding guidelines. - Ability to manage multiple priorities simultaneously and effectively handle the emotional stress of the workload. - Ability to work independently exercising confidentiality, discretion and independent judgement. - Ability to work in collaboration with other disciplines within the organization.

Role Description This role provides analysis of the highest dollar and most complex claims by applying research, coding standards, industry knowledge, and federal regulations to ensure correct billing practices. In this role, the incumbent will perform itemized bill reviews to identify billing abnormalities, unbundling, questionable billing practices, and improper coding combinations from a clinical and coding perspective and document denial reasoning or erroneous activity. - Review and analyze complex inpatient and outpatient charges of various revenue centers with consideration to patient diagnosis, procedures, age, and facility type including any additional information perceived as unbundled items and/or inappropriate charges. - Document audit results and update systems accordingly. Assist management in the daily operations and processes within the department. - Identify opportunities for recovery and avoidance. Research opportunities to better control overpayments and present ideas to management. - Drive successful coding operations through the application of learned, certified knowledge in addition to continuous professional development and ongoing coding research. - Provide general support to clinical team members, serving as a resource and subject matter expert (SME). - Monitor turnaround times for multiple applications and provide suggestions for process efficiencies. - Use independent decision-making skills to review claims after business hours to meet deadlines. - Apply national coding standards and regulations to claims billed. - Research and review individual claims, claim trends, or detailed itemized bills, operative notes, and other documentation as needed. - Monitor, research, and summarize trends, coding practices, and regulatory changes. - Apply clinical judgment and high level of expertise along with analytic skills in review of the most challenging and difficult cases; including conducting additional research as needed. - Communicate clinical, coding, and reimbursement findings to co-workers and management in a clear, organized manner. - Partner with management to drive department goals and objectives. - Collaborate, coordinate, and communicate across disciplines and departments. - Ensure compliance with HIPAA regulations and requirements. - Demonstrate Company's Core Competencies and values held within. - Please note due to the exposure of PHI sensitive data -- this role is considered to be a High Risk Role. - The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary. Qualifications - Completion of educational curriculum required of medical license or coding certification held with Bachelor's Degree preferred; and at least 5 years of coding experience. - Minimum 5 years experience in direct patient care, medical procedure billing, medical insurance auditing, line item review, audits, coding, and/or reimbursement. - Extensive knowledge of inpatient/outpatient hospital billing including UB-04s, revenue codes, itemization of charges, CPT codes, HCPCS codes, ICD-10 diagnoses and procedure codes. - Knowledge of payer reimbursement policies, state and federal regulations, medical necessity criteria, and applicable industry standards. - Knowledge of commonly used medical data resources. - Auditing and health information management experience in a healthcare setting preferred. - Experience with facility contract interpretation. - Experience and proficiency using MS Office Suites: Excel, Outlook, and PowerPoint. - Excellent communication (written, verbal, and listening), interpersonal, organizational, time-management, analytical, problem-solving, troubleshooting, customer service skills. - Ability to develop educational materials and job aids pertaining to coding and claims. - Ability to work evening or weekend hours as needed to meet deadlines. - Ability to handle multiple tasks in a fast-paced environment. - Ability to meet individual and team goals, deadlines, and work standards. - Ability to apply independent judgment and determine appropriate course of action. - Ability to read and abstract medical records. - Knowledge of medical terminology, anatomy, and physiology. - Ability to interact and discuss results with providers. - Ability to lead, teach, mentor others, and facilitate a learning environment. - Individual in this position must be able to work in a standard office environment which requires sitting and viewing monitor(s) for extended periods of time, operating standard office equipment such as, but not limited to, a keyboard, copier, and telephone. Requirements This section is intentionally left blank. Benefits - Medical, dental, and vision coverage with low deductible & copay. - Life insurance. - Short and long-term disability. - Paid Parental Leave. - 401(k) + match. - Employee Stock Purchase Plan. - Generous Paid Time Off – accrued based on years of service. - WA Candidates: the accrual rate is 4.61 hours every other week for the first two years of tenure before increasing with additional years of service. - 10 paid company holidays. - Tuition reimbursement. - Flexible Spending Account. - Employee Assistance Program. - Sick time benefits – for eligible employees, one hour of sick time for every 30 hours worked, up to a maximum accrual of 40 hours per calendar year, unless the laws of the state in which the employee is located provide for more generous sick time benefits. Company Description This section is intentionally left blank. Application Deadline We will generally accept applications for at least 5 calendar days from the posting date or as long as the job remains posted.

• Audit and authorize reimbursement of specific and/or aggregate medical stop loss claims • Effectively mitigate client medical stop loss claims and provide excellent customer service • Analyze and adjudicate stop loss claims and request appropriate reimbursement from carrier • Recognize cost mitigation opportunities • Authorize and release stop loss claims reimbursement checks at or below pre-set authority limits • Initiate claims investigations and vendor referrals • Interpret plan language, and identify experimental services and subrogation opportunities • Identify need for follow-up on pended claims and resolution • Communicate effectively with carriers, vendors, and management • Provide full claims service to both phone and written inquiries • Generate and maintain claims system reports to adjust reserves, identify pending and backlog claims, and provide renewal and enrollment/premium history • Develop new and review old stop loss claim forms • Assist with internal auditing of claims auditors, and training of claims auditors

• Performs audits of medical record documentation to determine the accuracy of principal and secondary diagnosis (including MCC & CC) and procedure codes. • Adheres to official coding guidelines, coding clinics and regulatory guidelines and mandates. • Draws on advanced ICD-10 coding expertise to substantiate conclusions. • Utilizes proprietary auditing systems with a high level of proficiency to document audit determinations and rationale. • Consistently achieves productivity and quality performance standards established by management. • Actively cross-trains to perform reviews of multiple claim types to provide a flexible workforce to meet client needs. • Assists management with training new Coding Auditors to include daily monitoring, mentoring, feedback and education. • Maintains current knowledge of coding guidelines and successfully completes required CEUs to maintain coding certification. • Responsible for attending training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.