Job Details

Job Description

JOB SUMMARY

Under general supervision, performs risk-based audits of clinical documentation, coding, and billing records to ensure that documentation supports services billed and complies with applicable regulatory and organizational requirements. This position independently validates documentation and coding compliance, identifies areas of compliance risk, and supports internal audit activities and external audit readiness across hospital-and provider-based settings. This role is outcome-driven and requires the ability to independently manage audit workload, documentation, and deadlines.

ESSENTIAL FUNCTIONS

• Performs risk-based audits of clinical documentation, physician, technical, and specialty billing and payment records by analyzing medical records, coding records, and health system bills to validate that documentation supports services billed and complies with applicable regulations and guidelines.

• Evaluates the accuracy and appropriateness of coding, billing, and documentation practices, including assessment of medical necessity, level of service, and adherence to federal, state, and payer specific requirements.

• Conducts audits across professional fee, hospital, and specialty services, including inpatient, outpatient, procedural, and ancillary services, as applicable.

• Identifies patterns, trends, and outliers in documentation and coding practices and escalates identified compliance risks through appropriate compliance governance channels.

• Utilizes audit findings, internal data, and regulatory focus areas to support the development and execution of risk-based audit plans aligned with organizational priorities.

• Supports responses to external audit requests (e.g., government, payer, and regulatory reviews) through documentation review, validation, and compliance risk assessment.

• Conducts targeted internal reviews in response to external audit findings or identified areas of compliance risk.

• Maintains complete, accurate, and defensible audit workpapers supporting audit conclusions and quality assurance review.

Prepares clear, concise audit reports summarizing findings, risk areas, and recommendations for Compliance leadership and stakeholders.

• Works collaboratively with appropriate personnel, including Revenue Cycle, Coding, and operational teams, to support compliance objectives while maintaining independent audit judgment.

• Communicates audit findings and identified risk area to appropriate stakeholders to support follow-up activities led by designated education or operational teams.

• Develops and maintains audit tools, methodologies, and workflows to support consistent and effective audit execution. Identifies opportunities for process improvement related to internal auditing and compliance monitoring activities. QUALIFICATIONS -

Education - Required

• Bachelor’s Degree in Health information management, Healthcare Administration, or related field, or equivalent experience.

Experience - Required

• 3 years of progressive experience in coding, and or regulatory compliance auditing in a healthcare setting.

Experience - Preferred

• Experience performing provider-side and hospital-based documentation and coding audits strongly preferred. Knowledge, Skills and Abilities -

Required

• Strong knowledge of federal and state laws, third party payer regulations, and documentation and coding requirements.

• Demonstrated ability to perform independent, defensible audit analysis and communicate findings effectively to clinical and operational stakeholders

. • Strong organizational, problem-solving, and communication skills, with the ability to manage multiple priorities and deadlines in a complex environment.

• Experience working in Epic or similar electronic health record systems.

• Proven ability to manage change and work effectively in changing regulatory environments.

• Strong knowledge of federal and state laws, third-party payer regulations, and documentation and coding requirements.

• Strong communication and interpersonal skills with a high degree of professionalism when engaging with clinicians, coding professionals, and operational stakeholders.

• Effective problem-solving skills, with the ability to perform independent, defensible audit analysis. Licenses and Certifications -

Required

• CPC - Certified Professional Coder - American Academy of Professional Coders Upon Hire or

• CCS-P - Certified Coding Specialist-Physician Based - American Health Information Management Association Upon Hire or

• RHIA - Registered Health Information Administrator - American Health Information Management Association Upon Hire or

• RHIT - Registered Health Information Technician - American Health Information Management Association Upon Hire or

• CIC - Certified Inpatient Code - American Academy of Professional Coders Upon Hire or

• COC - Certified Outpatient Coder - American Academy of Professional Coders Upon Hire Licenses and Certifications - Preferred

• CRC - Certified Risk Adjustment Coder - American Academy of Professional Coders Upon Hire or

• CHC - Certified Healthcare Compliance - Compliance Certification Board Upon Hire

PHYSICAL DEMANDS/WORKING CONDITIONS

Remote

Usual Workday Hours:

8 WORK ENVIRONMENT Functional Demands

☐ Sedentary Very light energy Full Description level Lift and carry 7 lbs., continuous sitting >67%, frequent keyboard use/repetitive motion, frequent fine motor activity/wrist position deviation

Work Shift

Worker Sub Type

Employee Entity

Primary Location Address

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.    

Jefferson is committed to providing equal educa­tional and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status. 

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

For more benefits information, please click here