Compliance Audit Specialist

Job Description Summary

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JOB PROFILE SUMMARY
Compliance Coding Chart Auditor II is responsible for independently conducting comprehensive medical chart audits to evaluate the accuracy, completeness, and regulatory compliance of clinical documentation, diagnosis coding (ICD-10), risk adjustment, and professional medical services billing.
This team member performs retrospective and prospective medical record reviews to assess compliance with ICD-10-CM diagnosis coding guidelines, Hierarchical Condition Category (HCC) risk adjustment require-ments, Evaluation and Management (E/M) documentation and coding guidelines, Current Procedural Termi-nology (CPT) coding standards, and Healthcare Common Procedure Coding System (HCPCS) Level II re-quirements.
The role is responsible for identifying unsupported diagnoses, inaccurate code assignments, incorrect E/M ser-vice levels, improper procedure coding, and documentation deficiencies. The auditor documents findings, communicates results to healthcare providers, and supports provider education to improve documentation quality, coding accuracy, and maintain regulatory compliance.

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How will you make an impact & Requirements

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Millennium Physician Group is one of the largest comprehensive primary care practices in Florida, serving communities through a value-based care model focused on improving patient outcomes and enhancing the healthcare experience. As part of Mosaic Health, MPG is committed to delivering coordinated, patient-centered care while partnering with health plans, providers, and community organizations to improve the health of the populations it serves.

KEY RESPONSIBILITIES

• Review provider documentation, including history of present illness (HPI), review of systems (ROS), physical examination, assessment and plan, diagnostic findings, treatment plans, and relevant supporting records.
• Determine whether the medical record adequately supports the diagnoses, procedures, services, and codes reported on medical claims.
• Evaluate the consistency between provider documentation, assigned codes, billed services, and applicable coding guidelines.

ICD-10-CM Diagnosis Coding Audits

• Conduct detailed reviews of ICD-10-CM diagnosis codes assigned to medical encounters and submitted on healthcare claims.
• Verify that reported diagnoses are supported by provider documentation and meet applicable ICD-10-CM Official Guidelines for Coding and Reporting.

HCC Risk Adjustment Coding and Documentation Audits

· Perform medical record audits to evaluate the accuracy and documentation support of Hierarchical Condition Category (HCC) diagnoses used in applicable risk adjustment models.

• Review diagnoses submitted for risk adjustment to determine whether they are supported by appropriate provider documentation and meet applicable CMS and payer requirements.

Evaluation and Management (E/M) Coding Audits

• Perform comprehensive audits of E/M services to determine whether billed CPT codes and service levels are supported by the medical record.
• Review of medical decision-making (MDM) documentation, including:
  • Number and complexity of problems addressed.
  • Amount and complexity of data is reviewed and analyzed.
  • Risk of complications, morbidity, or mortality associated with patient management.
• Evaluate time-based E/M coding when time is used to select the service level, including the documentation of qualifying practitioner time and applicable coding requirements.

CPT Procedure Coding and Medical Necessity Audits

• Conduct audits of CPT procedure codes to verify that billed procedures are accurately represented and supported by medical record documentation.
• Review documentation supporting diagnostic, therapeutic, preventive, and other professional medical procedures.

Provider Education and Clinical Documentation Improvement

• Communicate medical chart audit findings to healthcare providers and share documentation and improvement opportunities to maintain organizational coding accuracy standards.

Regulatory Research and Continuous Compliance Improvement

• Research and interpret applicable CMS regulations, Medicare manuals, ICD-10-CM guidelines, AMA CPT coding guidance, HCPCS requirements, and payer-specific policies.
• Maintain current knowledge of annual and periodic changes to diagnosis codes, procedure codes, E/M guidelines, and risk adjustment requirements.
• Maintain current coding certifications

EDUCATION AND EXPERIENCE

• Minimum of 2–4 years of experience in medical coding, medical chart auditing, coding compliance, and risk adjustment coding.
• Demonstrated experience reviewing provider documentation and medical claims for ICD-10-CM diagnosis coding accuracy.
• Experience evaluating HCC risk adjustment diagnoses and associated medical record documentation. Experience auditing E/M services using current medical decision-making and time-based coding guidelines.

Required Professional Certifications

Current, active certifications from the American Academy of Professional Coders (AAPC) or American Health Information Management Association (AHIMA):

• Certified Professional Coder (CPC) Demonstrates proficiency in physician and outpatient coding, including ICD-10-CM, CPT, and HCPCS Level II.
• Certified Professional Medical Auditor (CPMA) Demonstrates knowledge of medical record auditing, coding compliance, documentation review, and regulatory requirements.
• Certified Risk Adjustment Coder (CRC) Demonstrates proficiency in risk adjustment coding, HCC diagnosis validation, and supporting clinical documentation requirements.

Required Knowledge and Technical Skills

• Strong working knowledge of ICD-10-CM Official Guidelines for Coding and Reporting.
• Comprehensive understanding of HCC risk adjustment coding methodologies and applicable CMS documentation requirements.
• Knowledge of current AMA CPT E/M guidelines, including medical decision-making, time-based coding, and appropriate modifier usage.
• Strong analytical skills and attention to detail when reviewing complex medical records and claims data.
• Proficiency in electronic health record (EHR) systems, coding references, audit tracking systems, and Microsoft Office applications, particularly Excel, Word, and Outlook.
• Ability to prepare well-organized audit workpapers and clearly written findings supported by applicable authoritative guidance.

Communication and Professional Competencies

· Excellent written and verbal communication skills, including the ability to explain complex coding and documentation requirements to healthcare providers.

· Strong organizational and time-management skills, with the ability to manage multiple audit assignments and meet deadlines.

· Ability to exercise sound professional judgment, objectivity, and discretion when evaluating medical documentation and coding practices.

· Demonstrated commitment to accuracy, confidentiality, professional ethics, and regulatory compliance.

· Ability to work independently while collaborating effectively with senior auditors, Compliance leadership, Coding, Revenue Cycle, and healthcare providers.

· Ability to provide constructive feedback and support provider education in a professional and collaborative manner.

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Compensation Range:

$63,982.00

to

$95,972.00

The anticipated base salary range represents the Company's good-faith estimate of the compensation it reasonably expects to pay for this position at the time of posting. Actual compensation will be determined based on factors including experience, skills, qualifications, geographic location, internal equity, and business needs.