Salary Range: $80,000 - $100,000

By adhering to Connecticut State Law, pay ranges are posted. The pay rate will vary based on various factors including but not limited to experience, skills, knowledge of position and comparison to others who are already in this role within the company.

Flu Vaccine Considerations
Proof of annual flu vaccination is required for all employees.

Summary

The Medical Auditor is responsible for coordinating and conducting medical billing, coding, and documentation audits to ensure compliance with federal, state, and commercial payer regulations, organizational policies, and industry standards. This role evaluates provider documentation, coding accuracy, billing practices, and revenue cycle processes across multiple clinical specialties and care settings. The Medical Auditor provides education, consultation, and recommendations to clinicians, clinical staff, and operational leaders to improve documentation integrity, coding accuracy, regulatory compliance, and revenue optimization. This position works closely with physicians, advanced practice providers, coding and billing personnel, revenue cycle leadership, compliance officers, operational leaders, and other healthcare stakeholders to promote compliant documentation, coding, billing, and reimbursement practices.

Essential Functions

Audit and Compliance Activities

• Conduct routine and focused audits of medical records, provider documentation, coding, billing, and reimbursement practices in accordance with the Compliance Work Plan and departmental priorities.
• Perform independent reviews of professional, outpatient, inpatient, home health, skilled nursing facility, and other healthcare service documentation to assess compliance with applicable regulations and payer requirements.
• Evaluate provider documentation for ICD-10, CPT, HCPCS, and E/M coding accuracy and compliance with organizational, governmental, and payer guidelines.
• Validate charges and billing activity against supporting medical record documentation.
• Review encounter forms, charge documents, operative reports, procedural reports, medical records, and billing workflows to identify compliance risks and coding opportunities.
• Participate in audits conducted or requested by government agencies, commercial payers, or other third-party entities.

Analysis and Reporting

• Analyze audit findings, identify trends, control deficiencies, documentation gaps, and compliance vulnerabilities.
• Prepare detailed audit workpapers, reports, and supporting documentation in accordance with established standards.
• Develop and maintain audit tracking logs, databases, dashboards, and reports to monitor audit activities and corrective action progress.
• Utilize data analysis and reporting tools to identify billing trends, high-risk areas, and opportunities for focused reviews.
• Present findings and recommendations to compliance leadership, department management, and other stakeholders.

Corrective Action and Education

• Collaborate with operational and clinical leaders to develop corrective action plans addressing identified audit findings.
• Monitor implementation and effectiveness of corrective actions and validate sustained compliance improvements.
• Conduct education and training sessions for physicians, providers, coders, billers, and clinical staff on coding, documentation, compliance, and regulatory requirements.
• Assist in the development of training materials, compliance resources, and educational programs.
• Serve as a subject matter expert regarding coding, billing, documentation, and compliance requirements.

Compliance Program Support

• Assist with investigations related to compliance concerns, hotline reports, and potential billing or documentation issues.
• Support the development, revision, and implementation of compliance policies and procedures.
• Participate in enterprise risk assessments and compliance monitoring activities to support annual audit planning.
• Contribute to ongoing compliance program initiatives and organizational efforts to promote ethical billing and coding practices.
• Remain current on regulatory changes, payer updates, coding revisions, and industry best practices affecting healthcare reimbursement and compliance.

Skills and Knowledge

• Thorough understanding of the contents of multi-specialty medical records in order to identify information to support
• Thorough knowledge and experience in EHR, preferably EPIC.
• Basic knowledge of anatomy and physiology of human body and diseases in order to understand etiology, pathology, symptoms, signs, diagnostic studies, treatment modalities, and procedures to be
• Basic understanding of claims form and reimbursement process
• Understanding of local medical policies of carriers and

Education and Experience

• Bachelor's degree in healthcare administration, Health Information Management, Nursing, Business, Finance, or a related healthcare field required.
• Minimum of three to five (3-5) years of experience in healthcare auditing, compliance, physician billing, coding, revenue integrity or related healthcare operations.
• Experience performing documentation, coding, and billing audits in a healthcare system, academic medical center, physician practice, consulting organization, or related setting preferred.
• Experience auditing Evaluation and Management (E/M) services and professional claims required.
• Certified Professional Coder (CPC) required
• Certified Professional Medical Auditor (CPMA) strongly preferred
• Other relevant coding or auditing certifications may be considered