Senior Professional Fee Compliance Auditor and Educator

Job Requirements Functions as a trusted advisor to compliance, revenue cycle, operational, clinical, and executive leadership regarding complex regulatory, documentation, coding, billing, reimbursement, and compliance matters. Leads the development, implementation, and continuous improvement of the professional fee compliance auditing program, including risk-based audit planning, monitoring activities, and system-wide compliance initiatives.

Serves as the organization's subject matter expert in professional fee documentation, coding, billing compliance, and regulatory requirements. Leads complex, high-risk audits, investigations, and special projects to evaluate compliance with applicable laws, regulations, coding guidelines, and organizational policies; identifies emerging risks, assesses organizational impact, and develops mitigation strategies. Provides advanced education, consultation, and technical guidance to providers, operational leaders, and compliance professionals, and prepares and presents audit findings, trend analyses, and recommendations to leadership.

Work requires a high degree of independent judgment, technical expertise, professional discretion, strategic thinking, and the ability to influence organizational decision-making. Work Experience Primary Responsibilities The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all

• performed.
• Lead complex, high-risk, and system-wide professional fee compliance audits to assess the adequacy of medical record documentation supporting codes selected by providers and/or coders.
• Maintain annual and ongoing risk-based professional fee compliance audit plans using regulatory, operational, financial, audit-history, and organizational risk indicators.
• Verify compliance with CMS guidelines, CPT, HCPCS, ICD-10, and internal coding and billing policies through documentation and coding audits.
• Analyze documentation, coding, billing, and reimbursement patterns across providers, divisions, departments, specialties, and member organizations to identify systemic compliance vulnerabilities; assess operational, financial, regulatory, and reputational impact; and develop enterprise-level corrective action and risk-mitigation strategies.
• Serve as the department's senior subject matter expert for professional fee documentation, coding, billing compliance, reimbursement, and regulatory interpretation, providing strategic consultation to compliance, revenue cycle, operational, clinical, and executive leadership.
• Develop and deliver targeted education, training programs, and compliance resources to address deficiencies identified through audits and support system-wide compliance initiatives.
• Present audit findings, recommendations, and compliance risks to providers, provider groups, practice administrators, and organizational leadership.
• Mentor and provide technical guidance to auditors and compliance staff on auditing methodologies, regulatory interpretation, and effective use of audit tools and resources.
• Conduct regulatory research, monitor changes in billing and coding requirements, assess organizational impact, and recommend actions to maintain compliance.
• Lead complex compliance investigations and reviews involving documentation, coding, billing, and reimbursement concerns, including preparation of findings and recommendations.
• Lead the design, implementation, standardization, and continuous improvement of enterprise professional fee audit methodologies, standard operating procedures, monitoring tools, quality standards, toolkits, checklists, and educational resources
• Develop and prepare executive-level reports, dashboards, trend analyses, and presentations regarding audit outcomes, compliance risks, and regulatory developments for organizational leadership and compliance committees.
• Lead complex, cross-functional, and enterprise-wide compliance initiatives involving multiple departments, specialties, service lines, member organizations, and leadership stakeholders, including initiatives related to risk reduction, audit program effectiveness, corrective action, and technology optimization.
• Perform all other duties as assigned. Education & Experience - Required
• High school diploma.
• Seven (7) years of coding experience, including four (4) years of auditing or compliance experience.
• Certified Professional Coder (CPC) or Certified Professional Medical Auditor (CPMA). Education & Experience - Preferred
• Experience in Corporate Compliance.
• Certified Coding Specialist (CCS), Certified Coding Specialist-Physician Based (CCS-P), Registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT) certification.
• Experience with MDaudit or similar compliance auditing software.
• Experience leading complex or enterprise-wide compliance audits.
• Experience leading compliance-related projects or process improvement initiatives. Knowledge, Skills, & Abilities
• Advanced knowledge of CPT, ICD-10-CM, HCPCS, E/M guidelines, and modifiers for appropriate reporting of professional fee services.
• Expert knowledge of federal and state healthcare regulatory requirements, Medicare and Medicaid billing rules, compliance-program guidance, regulatory enforcement trends, reimbursement requirements, and organizational risk-mitigation strategies related to professional fee services.
• Advanced knowledge of compliance auditing and monitoring techniques, risk assessment methodologies, and corrective action planning.
• Working knowledge of compliance audit software (e.g., MDaudit) and related reporting and analytics tools.
• Ability to lead complex, high-risk, and system-wide compliance audits, investigations, and special projects.
• Ability to interpret and apply complex regulatory guidance and assess the operational impact of regulatory and reimbursement changes.
• Ability to independently identify and prioritize enterprise compliance risks, analyze trends and root causes, assess operational, financial, regulatory, and reputational impact, and formulate strategic recommendations that influence compliance policy, audit-program direction, educational priorities, and risk-mitigation decisions.
• Ability to serve as a senior subject matter expert and provide consultation to providers, operational leaders, revenue cycle leaders, and compliance leadership regarding coding, billing, and regulatory compliance matters.
• Strong analytical, critical thinking, planning, organizational, and problem-solving skills with attention to detail and accuracy.
• Ability to mentor and provide technical guidance to auditors and compliance staff while promoting consistent audit methodologies and quality standards.
• Effective skill in developing and presenting audit findings, trend analyses, reports, and recommendations to stakeholders and organizational leadership.
• Excellent verbal, written, interpersonal, and presentation skills with the ability to influence stakeholders and work effectively both independently and collaboratively in a fast-paced environmen Benefits All your information will be kept confidential according to EEO guidelines.

$36.83 - $55.29 Other Compensation (if applicable): Review the 2025-2026 UMMS Benefits Guide

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