Job DescriptionThe Anesthesia Auditor is responsible for the systematic review of anesthesia records to ensure accuracy, completeness, and compliance with regulatory and institutional standards. Primary responsibilities include verifying that all required documentation, provider signatures, and charges are present and appropriately supported. This role plays a key part in supporting quality assurance and regulatory compliance within the anesthesia department. The Anesthesia Auditor will also assist with other auditor duties as assigned.
Key Responsibilities:- Comprehensive review of anesthesia records to ensure documentation accuracy and completeness
- Verify that all required provider signatures- including those of the anesthesiologist, CRNA, and supervising physician- are present on the documentation
- Maintain adherence to internal protocols, external regulatory standards- including CMS and the Joint Commission- and all applicable billing requirements; additionally, identify all state-specific requirements necessary for compliance and billing in each jurisdiction (e.g., anesthesia assistants, supervision mandates, provider scope of practice)
- Detect gaps in documentation and follow up with providers to ensure completion and signature requirements are met
- Monitor, track, and report recurring errors or documentation trends to providers to support process improvement initiatives and education
- Collaborate with billing, compliance, and clinical departments to address documentation, regulatory, and process-related needs
- Ensure the secure and confidential handling of all medical records and patient information in accordance with HIPAA and organizational policies
- Assist with other audit and monitoring duties as assigned to include:
- Conduct detailed Hospital, Ambulatory Surgery Center, and Outpatient Clinic audits to ensure all charges are captured, supported by orders, and appropriately documented; additionally, review audit findings with the appropriate representative
- Execute special audits on an ongoing basis, summarizing results for executive leadership and coordinating education and training efforts as needed
- Analyze billing and compliance issues through the lens of federal and state healthcare regulations, as well as payer guidelines to ensure regulatory compliance
- Deliver targeted education on billing and compliance matters identified during reviews or upon request from facilities, administration, and management, employing webinars, presentations, bulletins, newsletters, SHINE modules, and other appropriate tools
Required Qualifications:- Minimum of 5 years' experience in medical chart review, medical auditing, or clinical documentation
- Functional knowledge of DRG and CPT coding systems
- Proficiency with Epic EMR
- Bachelor's Degree in Nursing, HIM, or related healthcare field - in lieu of degree, equivalent experience of at least 5 years in auditing and monitoring may be substituted for a degree
Preferred Qualifications:- Prior experience with anesthesia services or perioperative documentation
- Familiarity with regulatory requirements (e.g., CMS the Joint Commission, ASA guidelines)
- RHIA or RHIT certification
The pay range for this position is $73,569.60 - $110,344.00. Compensation is determined based on years of relevant experience and departmental equity.
