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Job Description Summary JOB PROFILE SUMMARY The Compliance Coding Chart Auditor II is responsible for independently conducting comprehensive, moderately complex medical chart audits to evaluate the accuracy, completeness, and regulatory compliance of clinical documentation, diagnosis coding, risk adjustment, and profes-sional medical services billing. This position performs retrospective and prospective medical record reviews to assess compli-ance with ICD-10-CM diagnosis coding guidelines, Hierarchical Condition Category (HCC) risk adjustment requirements, Evaluation and Management (E/M) documentation and coding guidelines, Current Procedural Terminology (CPT) coding standards, and Healthcare Common Procedure Coding System (HCPCS) Level II requirements. The auditor evaluates whether diagnoses, procedures, and services submitted on medical claims are accurately supported by provider documentation, meet applicable medical necessity re-quirements, and comply with Centers for Medicare & Medicaid Services (CMS), American Medical Association (AMA), and payer-specific guidelines. The role is responsible for identifying unsupported diagnoses, inaccurate code assignments, in-correct E/M service levels, improper procedure coding, documentation deficiencies, and poten-tial overpayments or underpayments. The auditor documents findings, communicates results to healthcare providers and operational leadership, and supports corrective action plans and pro-vider education to improve documentation quality, coding accuracy, and regulatory compli-ance. The Compliance Coding Chart Auditor II works independently within established audit meth-odologies and departmental procedures, exercising professional judgment in coding and docu-mentation reviews. The position collaborates with senior auditors, Compliance leadership, Cod-ing, Clinical Documentation Integrity (CDI), Revenue Cycle, and healthcare providers to identi-fy compliance risks and promote continuous improvement. How will you make an impact & Requirements KEY RESPONSIBILITIES undefined Independently conduct comprehensive medical chart audits to evaluate the accuracy, completeness, consistency, and compliance of clinical documentation supporting billed healthcare services. Perform retrospective and prospective medical record reviews across outpatient, physician office, and other assigned healthcare settings. Review provider documentation, including history of present illness (HPI), review of systems (ROS), physical examination, assessment and plan, diagnostic findings, treatment plans, and relevant supporting records. Determine whether the medical record adequately supports the diagnoses, procedures, services, and codes reported on medical claims. Evaluate compliance with applicable CMS documentation requirements, Medicare and Medicaid regulations, payer policies, and internal organizational standards. Evaluate the consistency between provider documentation, assigned codes, billed services, and applicable coding guidelines. Identify potential compliance risks involving unsupported services, inaccurate code selection, duplicate billing, and other coding or documentation discrepancies. Maintain accurate and complete audit documentation to support findings and recommendations. ICD-10-CM Diagnosis Coding Audits Conduct detailed reviews of ICD-10-CM diagnosis codes assigned to medical encounters and submitted on healthcare claims. Verify that reported diagnoses are supported by provider documentation and meet applicable ICD-10-CM Official Guidelines for Coding and Reporting. Evaluate diagnosis specificity, including anatomical location, laterality, severity, acuity, complications, and other required clinical details. Identify unsupported, unspecified, or inaccurately assigned diagnosis codes. Review coding for acute conditions, chronic diseases, manifestations, complications, and combination diagnoses. Determine whether documentation supports the diagnosis codes selected and whether clarification is needed. Document coding discrepancies and provide recommendations for correction and provider education. HCC Risk Adjustment Coding and Documentation Audits Perform medical record audits to evaluate the accuracy and documentation support of Hierarchical Condition Category (HCC) diagnoses used in applicable risk adjustment models. Review diagnoses submitted for risk adjustment to determine whether they are supported by appropriate provider documentation and meet applicable CMS and payer requirements. Evaluate documentation of chronic conditions, disease severity, complications, and other clinically relevant diagnoses affecting risk adjustment. Assess whether reported conditions were appropriately evaluated, monitored, assessed, or treated when required by applicable risk adjustment documentation standards. Identify unsupported HCC diagnoses, incorrect code assignments, documentation inconsistencies, and potential risk adjustment compliance concerns. Evaluation and Management (E/M) Coding Audits Perform comprehensive audits of E/M services to determine whether billed CPT codes and service levels are supported by the medical record. Evaluate E/M code selection based on applicable AMA CPT guidelines and CMS documentation and billing requirements. Review of medical decision-making (MDM) documentation, including: Number and complexity of problems addressed. Amount and complexity of data is reviewed and analyzed. Risk of complications, morbidity, or mortality associated with patient management. Evaluate time-based E/M coding when time is used to select the service level, including the documentation of qualifying practitioner time and applicable coding requirements. Assess whether the reported E/M level accurately reflects the documented medical decision-making or qualifying time. Identify potential E/M overcoding, undercoding, unsupported service levels, and documentation deficiencies. Review appropriate use of E/M modifiers, including modifier 25 when separately identifiable E/M services are reported with procedures. Evaluate compliance with applicable new and established patient requirements and other E/M coding rules. Review documentation supporting preventive medicine visits, problem-oriented visits, consultations, and other assigned E/M categories, as applicable. Provide recommendations for accurate E/M coding and improved provider documentation. CPT Procedure Coding and Medical Necessity Audits Conduct audits of CPT procedure codes to verify that billed procedures are accurately represented and supported by medical record documentation. Review documentation supporting diagnostic, therapeutic, preventive, and other professional medical procedures. Evaluate whether the procedure performed supports the CPT code billed, including the extent, complexity, and anatomical scope of the service. Evaluate compliance with National Correct Coding Initiative (NCCI) edits, procedure-to-procedure coding rules, and medically unlikely edits when applicable. Review appropriate use of CPT modifiers, including modifiers 25, 59, and applicable X{EPSU} modifiers. Identify incorrect procedure code selection, unbundling, duplicate billing, unsupported procedures, and modifier misuse. Identify coding and documentation deficiencies that may create reimbursement, regulatory, or compliance risks. Communicate findings and recommend corrective actions to improve CPT coding accuracy. HCPCS Level II Coding Audits Review HCPCS Level II codes assigned to healthcare claims to verify coding accuracy, documentation support, and compliance with applicable payer requirements. Evaluate documentation supporting medications, injections, supplies, durable medical equipment, diagnostic services, and other services reported using HCPCS Level II codes. Verify that the billed HCPCS code accurately reflects the documented item or service provided. Evaluate medical necessity and coverage requirements for applicable HCPCS services. Document audit findings and recommend corrective actions to reduce coding errors and billing compliance risks. Provider Education and Clinical Documentation Improvement Communicate medical chart audit findings to healthcare providers, Coding teams, and appropriate operational stakeholders. Provide individualized education regarding ICD-10-CM coding, HCC risk adjustment documentation, E/M coding, CPT procedures, and HCPCS Level II requirements. Explain documentation deficiencies and coding discrepancies using applicable regulatory requirements, official coding guidelines, and payer policies. Support provider education initiatives addressing recurring audit findings and identified compliance risks. Provide constructive, objective, and evidence-based feedback to healthcare providers. Support follow-up reviews to evaluate improvement in provider documentation and coding accuracy. Promote compliant documentation practices that accurately reflect patient conditions and services rendered. Audit Findings, Reporting, and Corrective Action Monitoring Prepare clear, accurate, and comprehensive audit findings identifying coding errors, documentation deficiencies, and potential compliance risks. Document the applicable coding guideline, regulatory requirement, or payer policy supporting each finding. Maintain detailed audit workpapers, including medical record references, original codes, recommended codes, discrepancy classifications, and supporting rationale. Support preparation of medical chart audit reports, summaries, and presentations for Compliance leadership and operational stakeholders. Track audit observations and monitor corrective action plans to support timely resolution of identified deficiencies. Participate in follow-up audits to determine whether corrective actions have been implemented effectively. Identify recurring coding and documentation trends and recommend process improvements. Escalate significant or potentially systemic compliance concerns to senior auditors or Compliance leadership. Maintain confidentiality and protect patient health information in accordance with HIPAA and organizational policies. Regulatory Research and Continuous Compliance Improvement Research and interpret applicable CMS regulations, Medicare manuals, ICD-10-CM guidelines, AMA CPT coding guidance, HCPCS requirements, and payer-specific policies. Maintain current knowledge of annual and periodic changes to diagnosis codes, procedure codes, E/M guidelines, and risk adjustment requirements. Maintain current coding certifications Monitor updates to Medicare coverage policies, NCCI edits, and relevant documentation standards. Participate in departmental quality assurance activities, coding discussions, and audit calibration sessions. Recommend opportunities to strengthen internal controls, documentation integrity, and coding compliance processes. QUALIFICATIONS Medical Chart Auditing and Documentation Compliance Independently conduct comprehensive medical chart audits to evaluate the accuracy, completeness, consistency, and compliance of clinical documentation supporting billed healthcare services. Perform retrospective and prospective medical record reviews across outpatient, physician office, and other assigned healthcare settings. Review provider documentation, including history of present illness (HPI), review of systems (ROS), physical examination, assessment and plan, diagnostic findings, treatment plans, and relevant supporting records. Determine whether the medical record adequately supports the diagnoses, procedures, services, and codes reported on medical claims. Evaluate compliance with applicable CMS documentation requirements, Medicare and Medicaid regulations, payer policies, and internal organizational standards. Identify potential compliance risks involving unsupported services, inaccurate code selection, duplicate billing, and other coding or documentation discrepancies. Maintain accurate and complete audit documentation to support findings and recommendations. ICD-10-CM Diagnosis Coding Audits Conduct detailed reviews of ICD-10-CM diagnosis codes assigned to medical encounters and submitted on healthcare claims. Verify that reported diagnoses are supported by provider documentation and meet applicable ICD-10-CM Official Guidelines for Coding and Reporting. Evaluate diagnosis specificity, including anatomical location, laterality, severity, acuity, complications, and other required clinical details. Identify unsupported, unspecified, outdated, incorrectly sequenced, or inaccurately assigned diagnosis codes. Review coding for acute conditions, chronic diseases, manifestations, complications, and combination diagnoses. Assess compliance with applicable ICD-10-CM coding conventions, instructional notes, exclusions, and sequencing requirements. Determine whether documentation supports the diagnosis codes selected and whether clarification is needed. Identify missed or incorrectly coded reportable conditions when supported by documentation and applicable coding rules. Document coding discrepancies and provide recommendations for correction and provider education. HCC Risk Adjustment Coding and Documentation Audits Perform medical record audits to evaluate the accuracy and documentation support of Hierarchical Condition Category (HCC) diagnoses used in applicable risk adjustment models. Review diagnoses submitted for risk adjustment to determine whether they are supported by appropriate provider documentation and meet applicable CMS and payer requirements. Evaluate documentation of chronic conditions, disease severity, complications, and other clinically relevant diagnoses affecting risk adjustment. Assess whether reported conditions were appropriately evaluated, monitored, assessed, or treated when required by applicable risk adjustment documentation standards. Identify unsupported HCC diagnoses, incorrect code assignments, documentation inconsistencies, and potential risk adjustment compliance concerns. Review the accuracy of diagnosis specificity and its impact on applicable HCC classifications. Identify opportunities to improve the completeness and accuracy of risk adjustment documentation without encouraging unsupported diagnosis reporting. Support compliance initiatives related to Medicare Advantage risk adjustment, diagnosis validation, and documentation integrity. Collaborate with healthcare providers and Coding teams to address HCC documentation deficiencies and improve coding accuracy. Evaluation and Management (E/M) Coding Audits Perform comprehensive audits of E/M services to determine whether billed CPT codes and service levels are supported by the medical record. Evaluate E/M code selection based on applicable AMA CPT guidelines and CMS documentation and billing requirements. Review of medical decision-making (MDM) documentation, including: Number and complexity of problems addressed. Amount and complexity of data is reviewed and analyzed. Risk of complications, morbidity, or mortality associated with patient management. Evaluate time-based E/M coding when time is used to select the service level, including the documentation of qualifying practitioner time and applicable coding requirements. Assess whether the reported E/M level accurately reflects the documented medical decision-making or qualifying time. Identify potential E/M overcoding, undercoding, unsupported service levels, and documentation deficiencies. Review appropriate use of E/M modifiers, including modifier 25 when separately identifiable E/M services are reported with procedures. Evaluate compliance with applicable new and established patient requirements and other E/M coding rules. Review documentation supporting preventive medicine visits, problem-oriented visits, consultations, and other assigned E/M categories, as applicable. Provide recommendations for accurate E/M coding and improved provider documentation. CPT Procedure Coding and Medical Necessity Audits Conduct audits of CPT procedure codes to verify that billed procedures are accurately represented and supported by medical record documentation. Review documentation supporting diagnostic, therapeutic, preventive, and other professional medical procedures. Evaluate whether the procedure performed supports the CPT code billed, including the extent, complexity, and anatomical scope of the service. Verify that medical necessity is documented in accordance with applicable CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and payer-specific requirements. Review provider orders, clinical indications, procedure notes, diagnostic reports, and other supporting documentation as applicable. Evaluate compliance with National Correct Coding Initiative (NCCI) edits, procedure-to-procedure coding rules, and medically unlikely edits when applicable. Review appropriate use of CPT modifiers, including modifiers 25, 59, and applicable X{EPSU} modifiers. Identify incorrect procedure code selection, unbundling, duplicate billing, unsupported procedures, and modifier misuse. Communicate findings and recommend corrective actions to improve CPT coding accuracy. HCPCS Level II Coding Audits Review HCPCS Level II codes assigned to healthcare claims to verify coding accuracy, documentation support, and compliance with applicable payer requirements. Evaluate documentation supporting medications, injections, supplies, durable medical equipment, diagnostic services, and other services reported using HCPCS Level II codes. Verify that the billed HCPCS code accurately reflects the documented item or service provided. Assess documentation supporting billed units, quantities, dosage, route of administration, and other applicable billing elements. Review appropriate use of HCPCS modifiers and applicable billing requirements. Identify unsupported HCPCS codes, incorrect units, duplicate billing, and discrepancies between documentation and claims. Evaluate medical necessity and coverage requirements for applicable HCPCS services. Document audit findings and recommend corrective actions to reduce coding errors and billing compliance risks. Provider Education and Clinical Documentation Improvement Communicate medical chart audit findings to healthcare providers, Coding teams, and appropriate operational stakeholders. Provide individualized education regarding ICD-10-CM coding, HCC risk adjustment documentation, E/M coding, CPT procedures, and HCPCS Level II requirements. Explain documentation deficiencies and coding discrepancies using applicable regulatory requirements, official coding guidelines, and payer policies. Develop educational recommendations and examples to improve the accuracy and completeness of provider documentation. Support provider education initiatives addressing recurring audit findings and identified compliance risks. Collaborate with Clinical Documentation Integrity, Compliance, and Coding teams to promote consistent documentation practices. Provide constructive, objective, and evidence-based feedback to healthcare providers. Support follow-up reviews to evaluate improvement in provider documentation and coding accuracy. Promote compliant documentation practices that accurately reflect patient conditions and services rendered. Audit Findings, Reporting, and Corrective Action Monitoring Prepare clear, accurate, and comprehensive audit findings identifying coding errors, documentation deficiencies, and potential compliance risks. Document the applicable coding guideline, regulatory requirement, or payer policy supporting each finding. Maintain detailed audit workpapers, including medical record references, original codes, recommended codes, discrepancy classifications, and supporting rationale. Classify audit findings by error type, severity, frequency, and potential compliance or reimbursement impact. Support preparation of medical chart audit reports, summaries, and presentations for Compliance leadership and operational stakeholders. Track audit observations and monitor corrective action plans to support timely resolution of identified deficiencies. Maintain confidentiality and protect patient health information in accordance with HIPAA and organizational policies. Regulatory Research and Continuous Compliance Improvement Research and interpret applicable CMS regulations, Medicare manuals, ICD-10-CM guidelines, AMA CPT coding guidance, HCPCS requirements, and payer-specific policies. Maintain current knowledge of annual and periodic changes to diagnosis codes, procedure codes, E/M guidelines, and risk adjustment requirements. Monitor updates to Medicare coverage policies, NCCI edits, and relevant documentation standards. Apply regulatory updates consistently throughout assigned audit activities. Participate in departmental quality assurance activities, coding discussions, and audit calibration sessions. Recommend opportunities to strengthen internal controls, documentation integrity, and coding compliance processes. EDUCATION AND EXPERIENCE Minimum of 2–4 years of progressively responsible experience in medical coding, medical chart auditing, coding compliance, risk adjustment coding, or related healthcare compliance functions. Demonstrated experience reviewing provider documentation and medical claims for ICD-10-CM diagnosis coding accuracy. Experience evaluating HCC risk adjustment diagnoses and associated medical record documentation. Experience auditing E/M services using current medical decision-making and time-based coding guidelines. Experience reviewing CPT procedure codes, HCPCS Level II codes, modifiers, and supporting clinical documentation. Experience interpreting CMS documentation requirements, coding guidelines, and payer policies. Experience communicating coding and documentation findings to healthcare providers and operational teams. Required Professional Certifications Current, active certifications from the American Academy of Professional Coders (AAPC): Certified Professional Coder (CPC) Demonstrates proficiency in physician and outpatient coding, including ICD-10-CM, CPT, and HCPCS Level II. Certified Professional Medical Auditor (CPMA) Demonstrates knowledge of medical record auditing, coding compliance, documentation review, and regulatory requirements. Certified Risk Adjustment Coder (CRC) Demonstrates proficiency in risk adjustment coding, HCC diagnosis validation, and supporting clinical documentation requirements. Certification requirement: CPC, CPMA, and CRC certifications are required for this position and must remain active and in good standing throughout employment. Required Knowledge and Technical Skills Strong working knowledge of ICD-10-CM Official Guidelines for Coding and Reporting. Comprehensive understanding of HCC risk adjustment coding methodologies and applicable CMS documentation requirements. Knowledge of current AMA CPT E/M guidelines, including medical decision-making, time-based coding, and appropriate modifier usage. Working knowledge of CPT procedure coding, HCPCS Level II codes, and applicable billing rules. Understanding of CMS National Coverage Determinations, Local Coverage Determinations, and medical necessity documentation requirements. Familiarity with Medicare and Medicare Advantage coding and documentation compliance. Knowledge of NCCI edits, coding bundling rules, and modifier requirements. Ability to identify coding discrepancies, unsupported diagnoses, insufficient documentation, and potential billing compliance risks. Strong analytical skills and attention to detail when reviewing complex medical records and claims data. Proficiency in electronic health record (EHR) systems, coding references, audit tracking systems, and Microsoft Office applications, particularly Excel, Word, and Outlook. Ability to prepare well-organized audit workpapers and clearly written findings supported by applicable authoritative guidance. Communication and Professional Competencies Excellent written and verbal communication skills, including the ability to explain complex coding and documentation requirements to healthcare providers. Strong organizational and time-management skills, with the ability to manage multiple audit assignments and meet deadlines. Ability to exercise sound professional judgment, objectivity, and discretion when evaluating medical documentation and coding practices. Demonstrated commitment to accuracy, confidentiality, professional ethics, and regulatory compliance. Ability to work independently while collaborating effectively with senior auditors, Compliance leadership, Coding, Revenue Cycle, and healthcare providers. Ability to provide constructive feedback and support provider education in a professional and collaborative manner. Strong problem-solving skills and ability to identify root causes of recurring coding and documentation deficiencies. Willingness to maintain professional knowledge through continuing education and ongoing review of coding and regulatory updates. EXPECTED PERFORMANCE AND ACCOUNTABILITY The Compliance Coding Chart Auditor II is expected to: Complete assigned medical chart audits accurately and within established timelines. Produce well-supported, objective, and reproducible audit findings. Apply ICD-10-CM, HCC, E/M, CPT, and HCPCS coding requirements consistently. Identify material documentation and coding compliance risks and escalate significant findings appropriately. Provide accurate and actionable provider education based on audit results. Maintain complete, organized, and confidential audit documentation. Support timely corrective action follow-up and compliance improvement initiatives. Demonstrate increasing independence in moderately complex medical chart audits while seeking guidance on unusual, high-risk, or complex regulatory issues. Compensation Range: $63,982.00 to $95,972.00 The anticipated base salary range represents the Company's good-faith estimate of the compensation it reasonably expects to pay for this position at the time of posting. Actual compensation will be determined based on factors including experience, skills, qualifications, geographic location, internal equity, and business needs. Beware of fraudulent job postings: While Mosaic Health job advertisements may be found on many sites, our current openings page and its associated Workday account are the only places we accept applications for open roles. If you suspect a job post is fraudulent, please let us know at recruiting@apree.health. Mosaic Health is a national care delivery platform focused on expanding access to comprehensive primary care for consumers with coverage across Commercial, Individual Exchange, Medicare, and Medicaid health plans. Learn More about Mosaic Health Learn More about Millennium Physician Group Learn More about CareMore Health Learn More about Castlight Health Learn More about Vera Whole Health 
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Verawholehealth
US-Florida-Remote, United States of America
Compliance Audit Specialist.
REMOTEFINANCE & LEGAL
more at Verawholehealth.
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