RCM Auditor

Role Overview

• Audit execution & oversight by performing routine and ad hoc audits across the full revenue cycle process, including: Charge entry and charge capture accuracy, CPT, HCPCS, and ICD-10 coding compliance, Modifier usage, Workers’ compensation billing rules and state-specific fee schedules, Claim submission accuracy and clean claim rates, Payment posting and adjustment accuracy, AR follow-up effectiveness and denial resolution workflows
• Conduct pre-bill and post-bill audits to identify trends impacting reimbursement and compliance
• Denial & Revenue leakage analysis: Analyze denial trends across WC, Medicare, and commercial payers, Identify root causes of denials and recommend corrective actions, Quantify revenue impact from: Coding errors, Missed charges, Underpayments, Inefficient workflows
• Ensure adherence to: CMS guidelines and Medicare billing requirements, NCCI (CCI edits) and payer-specific edits, State Workers’ Compensation regulations, Documentation standards for pain management procedures
• Support internal and external audit readiness (RAC, MAC, payer audits).
• Reporting & KPI development through audit dashboard Maintain monthly & quarterly records of all RCM, clinical, and provider audit scores and training requirements
• Partner with all BHC teams to develop and deliver targeted education based on audit findings.
• Assist in creating and updating SOPs and workflows to reduce errors and improve efficiency
• Establish and maintain quality assurance programs across RCM functions
• Perform routine QA reviews of staff productivity and accuracy
• Recommend automation opportunities and system enhancements
• Assumes other responsibilities as appropriate to the position and organizational needs

Requirements

• High school diploma or equivalent required; Associate degree preferred
• Active coding certification required: CPC, CCS, or equivalent (AAPC or AHIMA)
• 5+ years of experience in revenue cycle management
• 3+ years of auditing experience within healthcare billing or coding
• Strong experience in pain management
• Experience with Medicare and commercial payer guidelines
• Ability to work in a fast-paced environment, meet daily deadlines, and collaborate with cross-functional RCM teams
• Excellent communication skills with ability to present findings to providers and RCM leadership
• Advanced understanding of NCCI edits and payer-specific billing guidelines
• Accuracy and attention to detail, analytical thinking and problem solving and high integrity and compliance focus
• Advanced proficiency in Microsoft Excel (e.g., formulas, pivot tables) and solid skills in other Microsoft Office applications

Benefits

• Amazing work/life balance
• Generous Medical, Dental, Vision, and Prescription benefits (PPO & HMO)
• 401(K) Plan with Employer Matching
• License & Tuition Reimbursements
• Paid Time Off
• Holiday Pay & Floating Holiday
• Employee Perks and Discount Programs
• Supportive environment to help you grow and succeed