Compliance Billing & Coding Auditor II (Remote)

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This is a Stanford Health Care job.
A Brief Overview
Billing and Coding Compliance Auditors conduct audits and monitoring activities to identify and address compliance risks related to billing and coding practices. They review and evaluate healthcare regulatory compliance, focusing on the detection of documentation, coding, and billing errors. Responsibilities include assessing the adequacy and accuracy of documentation supporting billed services, including ICD, CPT, HCPCS, and other third-party payer codes, as well as adherence to Teaching Physician guidelines, Evaluation & Management criteria, DRG and APC assignments, medical necessity, and reimbursement accuracy.
Auditors serve as a communication channel, partnering with Billing and Coding Compliance Educators to address compliance issues. They are responsible for conducting thorough investigations into billing and coding compliance matters, ensuring adherence to regulatory standards, and identifying discrepancies. This role involves analyzing data, collaborating with relevant departments, and implementing corrective actions to enhance compliance and mitigate risks.
Career Banded Levels: Billing and Coding Compliance Auditor Family
There are three (3) career banded levels within the Billing and Coding Compliance Auditor family, with positions flexibly staffed at any of these levels. Progression to a higher level is contingent upon the need for the position, the nature, scope, and complexity of assigned duties, and the employee's demonstrated knowledge, skills, abilities, and professional behaviors.
Billing and Coding Compliance Auditor II is the full proficiency or journey level of the Billing and Coding Compliance Auditor Family where employees are responsible for independently performing the full range of duties of moderate difficulty and complexity as outlined under the Job Duties. Performs audits of limited scope with greater independence. May be responsible for determining audit scope, procedures, and key controls.
Locations
Stanford Health Care
What you will do

• Initiate and perform proactive coding and billing audits to identify potential coding and billing errors before claims submission, ensuring compliance with coding guidelines and reducing the risk of denials or audits by payers. May also conduct retrospective audits when required.

• Leverage auditing software and tools to streamline the auditing process, enhance data analysis capabilities, and improve the overall efficiency of billing and coding audits.

• Monitor and analyze billing and coding data to detect patterns of errors or non-compliance with regulatory standards and evaluate medical services for accuracy in the assignment of ICD, HCPCS, CPT codes, E&M, APC, DRG assignments, and charges.

• Review documentation supporting billed services to ensure accuracy and compliance and assist in identifying compliance risks through risk assessments based on previous audit findings and industry best practices.

• Conduct comprehensive investigations into billing and coding compliance issues to identify discrepancies and potential violations, including independent audits of facility and professional fee accounts for all patient types.

• Collaborate with relevant departments to gather information, evaluate documentation, and perform investigations related to potential compliance issues.

• Prepare detailed audit and investigative reports summarizing findings, recommendations for corrective actions, and areas for improvement, while monitoring the implementation of these actions to assess their effectiveness.

• Provide feedback to Billing and Coding educators to inform the development of training materials and enhance future educational content.

• Stay updated on federal, state, and payer regulations, as well as changes in healthcare regulations and coding guidelines, to ensure ongoing compliance.

• Participate in compliance training sessions and workshops to enhance knowledge and skills related to billing and coding practices and assist in developing compliance training content for various revenue cycle departments.

• Assist Billing and Coding educators in responding to inquiries regarding compliance matters.

• Contribute to the overall development and realization of the Office of Compliance and Privacy’s Risk Assessment, Workplan, and strategic goals.

Education Qualifications

• Associate’s degree in a work-related discipline/field from an accredited college or university (or equivalent combination of education/experience) required.

Experience Qualifications

• Minimum four (4) years of progressively responsible directly related work experience required.

• EPIC EHR experience preferred.

Required Knowledge, Skills and Abilities

• Ability to manage, organize, prioritize, multi-task and adapt to changing priorities.

• Ability to communicate effective in written and verbal formats including summarizing data and presenting results.

• Ability to provide leadership in problem identification and issue resolution.

• Ability to change the course of events through convincing arguments supported by data.

• Ability to apply Critical Thinking skills to issues and situations.

• Ability to mediate and solve complex work problems and issues.

• Ability to effectively facilitate work groups to successful outcomes.

• Knowledge of coding conventions including ICD-10-CM/PCS, HCPCS, E&M, and CPT.

• Knowledge of DRG/APC reimbursement.

• Knowledge of third party payer rules and regulations.

• Knowledge of healthcare compliance audit requirements, principles and techniques.

• Ability to plan, organize and conduct detailed healthcare corporate compliance functions and audits to identify and eliminate waste, fraud and abuse, and inefficiencies in conformance with prescribed laws, regulations and standards, reach independent decisions and logical conclusions, and prepare reports of findings and recommendations.

• Ability to model and demonstrate consistently high standards of professional ethics, integrity, and trust.

• Ability to maintain confidentiality of sensitive information.

• Ability to maintain competence in and up-to-date knowledge of healthcare compliance requirements, practices and trends.

• Knowledge of computer systems, specifically EPIC and 3M.

• Knowledge of computer software including Microsoft Word, Excel, and Power Point.

Preferred Knowledge, Skills and Abilities

• Hospital and/or Professional auditing experience in an Academic Medical Center.

Licenses and Certifications

• CCS - Certified Coding Specialist required within 180 Days or

• CCS-P - Certified Coding Specialist – Physician-based required within 180 Days or

• CPC - Certified Professional Coder required within 180 Days or

• CIC - Certified Inpatient Coder required within 180 Days or

• COC - Certified Outpatient Coder required within 180 Days

• CHC-Certification in Healthcare Compliance preferred .

These principles apply to ALL employees:
SHC Commitment to Providing an Exceptional Patient & Family Experience
Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families. Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other. C-I-CARE is the foundation of Stanford’s patient-experience and represents a framework for patient-centered interactions. Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery.
You will do this by executing against our three experience pillars, from the patient and family’s perspective:

• Know Me: Anticipate my needs and status to deliver effective care

• Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health

• Coordinate for Me: Own the complexity of my care through coordination

Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.

The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.