SUMMARY: The Audit Specialist is responsible for conducting audits of billing, documentation, insurance claims, medical records, and regulatory compliance activities. This role ensures adherence to Medicare, Medicaid, commercial insurance, and accreditation requirements while identifying opportunities to improve reimbursement accuracy, reduce audit risk, and support operational excellence. The Audit Specialist works closely with billing, customer service, intake, clinical, and management teams to monitor compliance with payer guidelines, validate documentation requirements, and support corrective action plans.
ESSENTIAL DUTIES AND RESPONSIBILITIES: Reasonable accommodations may be made to enable individuals with disabilities to perform these essential functions.
Compliance Auditing
- Perform routine and targeted audits of patient files, billing records, and supporting clinical documentation.
- Review documentation to ensure compliance with Medicare, Medicaid, commercial insurance, and accreditation standards.
- Verify that physician orders, medical necessity documentation, proof of delivery, and dispensing records meet payer requirements.
- Identify potential compliance risks and billing vulnerabilities.
Billing and Claims Auditing
- Audit submitted claims for coding accuracy and compliance with payer-specific guidelines.
- Review HCPCS coding, modifiers, and supporting documentation.
- Identify claim submission errors, denials, overpayments, and underpayments.
- Collaborate with billing staff to resolve discrepancies and implement corrective actions.
Documentation Review
- Validate completeness and accuracy of:
- Standard Written Orders (SWO)
- Medical Necessity Documentation
- Proof of Delivery (POD)
- Prior Authorizations
- Clinical Notes
- Certificates and supporting payer-required documentation
- Ensure records are maintained according to federal and state regulations.
Regulatory Compliance
- Maintain knowledge of CMS, Medicare, Medicaid, commercial payer regulations, and DME industry standards.
- Monitor regulatory updates affecting reimbursement and documentation requirements.
- Assist with preparation for external audits conducted by Medicare contractors, commercial payers, accreditation agencies, or government entities.
Reporting and Analysis
- Prepare audit reports outlining findings, trends, risk levels, and recommendations.
- Track audit metrics and monitor corrective action plans.
- Present findings to management and department leaders.
- Assist leadership in developing policies and procedures to strengthen compliance.
Education and Training
- Provide feedback and education to staff regarding audit findings.
- Participate in training initiatives related to documentation, billing accuracy, and compliance requirements.
- Support continuous quality improvement programs.
