Job Description

Job Title: Sr. Medical Auditor
Job ID: 664854
Status: Full-Time
Regular/Temporary: Regular
Shift: Day Job
Department: Corporate Compliance
Location: 5150 Centre Avenue, Pittsburgh PA 15232


Provides technical expertise to review staff to ensure that all physicians, clinical, billing and coding staff are adhering to all guidelines for compliance as set forth by governmental, regulatory agencies and third party payors. Provides quality assurance for internal audit processes; oversight to ensure review process is on target and ensures effective communication of regulation updates.

  • Adhere to human resources policies and procedures.
  • Assist the Compliance Manager and Compliance Officer with quality assurance activites and with reporting the overall results (i.e., effectiveness assessments) of the regular, special and CERT+ audit programs.
  • Attend department meetings and present educational update or discuss unique audit findings and recommendations as requested by the Compliance Manager. It is the Auditor's responsibility to seek out meetings that are specific to current auditor practice assignment and general continuing education.
  • Complete, review, and submit all audit spreadsheets and audit summaries to Compliance Manager as per audit schedule developed by Compliance Manager. Present draft audit results to the department/ractice staff and audited physicians and non-physician practitioners. This presentation must be well prepared and the auditor must have a thorough understanding of all issues cited in audit report and must present reference sources (with regulatory and rule-based exceprt language) within the report in support of audit findings.
  • Conduct post-audit compliance training sessions for PSD physicians and non-physician practitioners as audit results dictate. These training sessions will include, but are not limited to, provision of education specific to the issues found on audit and will be largely based on the documentation, coding and billing rules as set forth by CMS and other relevant Federal and State regulatory agencies.
  • Consult with physicians and physician staff, as needed, on documentation issues, requirements for supervision of resident services and other regulatory issues as they arise.
  • Develop an audit report, to accompany audit spreadsheet, which captures overall percentage of services coded correctly and supported by documentation in the medical record (non-refundable events), services determined to be at risk due to incorrect selection of code type, over-coding, under-coding, coding not supported by documentation in the medical record, misuse or absence of modifiers, bundling and other coding violations (refundable events), and other documentation, coding and billing concerns such as non-refundable modifier usage, ICD-9 diagnosis coding, date of service and etcetra. This audit summary report should conclude with recommendations to correct aforementioned areas of deficiencies including but not limited to departmental educational training sessions.
  • Develop and manage relationships with colleagues in a professional, independent manner to create an environment that affects necessary change to systems effecting the documentation, billing or coding services.
  • Develop computer based audit spreadsheet that accurately depict all coding/documentation discrepancies, identifies the patient and provider of service, and provides a clear and concise statement of deficiencies per line item. All points should be thoroughly researched and references made readily available upon completion of audit for manager or practice discussion.
  • Directs Medical Auditor, Junior Medical Auditor and Auditor Analyst as required or as requested Compliance Manager or Compliance Officer. Reviews work produced by these staff and provides feedback to Compliance Manager.
  • Engage in communication as directed or required with PSD executive management regarding internal and external audits and the results thereof.
  • Ensure adherence to PSD compliance program and regulatory related recommendations. Bring unresolved issues to the attention of the Compliance Manager and the Compliance Officer.
  • Maintain professional affiliations and enhance professional growth and development to keep current on the latest trends in health care.
  • Perform duties and job responsibilities in a manner that coincides with the service management philosophy of the PSD including the demonstration of the basics of service excellence toward patients, visitors, staff, peers, physicians and other departments within the medical center.
  • Perform internal retrospective, concurrent or prospective medical chart audits to assure that CPT codes billed are appropriate and supported by documentation in the patient record, and that all documentation and coding is compliant with Federal and State regulations. It is also the auditor's responsibility to note areas of determined lost revenue. All audit findings are the result of a thorough and complete review of all available documentation. It is the responsibility of the auditor to determine if all existing documentation has been reviewed. These audits will be performed according to guidelines set forth by regulatory agencies (CMS, OIG, DPW, etc.) and the National Committee of Quality Assurance. Concurrent audits may include the shadowing professional services to capture all billable services provided. Educational services may be provided simultaneously to the practice physician and practice staff as information in obtained. This responsibility includes a thorough knowledge of departmental chart and documentation flow, prior to the performance of a medical audit, to assure that documentation review encompasses all available records, as well as working closely with the Department Administrator, Chair, Practice Dir. to provide open communication lines during audit and educational processes.
  • Responsible for conducting and communication the results of special projects and all special audits as requested by the Compliance Manager or Compliance Officer.


  • Associates degree or comparable technical school diploma required.
  • Six years experience in coding and documentation of physician services is required.
  • In-depth knowledge of key revenue cycle processes, clinical documentation and financial operations.
  • Strong interpersonal and organizational skills.
  • Analytical and problem-solving skills.
  • Ability to coordinate the work of others and communicate effectively with physicians and practice managers.
  • Proficiency in MS Office.
  • Advanced knowledge of managed care, capitation and commercial third party payor billing and reimbursement practices as well as current legal requirements.
  • Excellent interpersonal, organizational, analytical and communication skills.
  • Ability to effectively communicate with all levels of the organizations.

    Licensure, Certifications, and Clearances:
  • Certified Coding Specialist or Certified Professional Coder or Registered Health Information Administrator or Registered Health Information Technician

UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $24.27 to $41.99

Union Position: No

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