Senior, Compliance Specialist - Coding & Clinical Documentation

Performs complex audit, inclusive of billing, coding, documentation, medical necessity, and general regulatory compliance analyses to ensure appropriate hospital reimbursement and adherence to applicable laws, regulations, and payer requirements.

Serves as a resource, with strong expertise in medical coding, inpatient and outpatient auditing, governmental payer regulations, and compliance methodologies.

Supports compliance education, training, and departmental process improvements to strengthen organizational integrity, coding accuracy, and mitigate risk. Provides targeted education to physicians, APPs, coders, and clinical staff on coding documentation and regulatory billing requirements.

Applies independent judgment and advanced analytical skills to interpret regulatory requirements, evaluate coding practices, identify areas of risk, and provide expert compliance guidance across clinical and revenue cycle operations.

Key Responsibilities

• Performs complex regulatory, audit, billing, coding, documentation, medical necessity, and general compliance analyses to ensure appropriate hospital reimbursement and adherence to applicable laws, rules, guidelines, and regulations.

• Provides support and assistance in refining compliance methodologies and improving departmental work products.

• Delivers ongoing compliance education and training to support organizational adherence to regulatory requirements.

• Researches and responds to complex compliance inquiries.

• Ensures the accuracy and timely completion of complex compliance audits, investigations, reviews, and the Annual Compliance Work Plan.

• Demonstrates extensive experience and expertise in:

  • Billing and medical auditing

  • Medical necessity

  • Proper documentation and coding

  • Inpatient and outpatient services

  • Governmental payer regulations and requirements

• Utilizes strong skills in report writing, findings analysis, and the ability to enter, manipulate, and analyze data within database applications and compliance systems.

• Maintains familiarity with a wide range of compliance concepts, practices, and procedures.

• Applies independent judgment and professional experience to plan and accomplish assigned goals.

• Performs a variety of compliance-related tasks as assigned.

• Provides compliance advice and guidance to stakeholders across the organization.

• Exercises a high degree of creativity, initiative, and professional latitude in the performance of duties.

Minimum Education and Experience Requirements

• Bachelor’s degree required

• Minimum of three (3) years of experience in compliance, clinical, coding, auditing, legal, or related work

• CHC (Certified in Healthcare Compliance) credential required

• RN, LPN, RHIA, RHIT, CPMA, or CCS credentials preferred

• Familiarity with hospital billing systems and medical records, with demonstrated coding and billing experience

• Knowledge of Medicare, Medicaid, and applicable state and federal laws and regulations governing the healthcare industry

• Proven problem-solving ability

• Must be organized, versatile, and able to work independently

Licensure / Certification / Registration

• CHC certification required, or ability to obtain within nine (9) months of hire