Healthcare Coding Compliance Auditor - RUHS

Full Job Description

Riverside University Health System (RUHS) is seeking two skilled Coding Compliance Auditors (Administrative Services Manager I) to support the Health System's Compliance Department.

Key responsibilities of this role include conducting thorough reviews of medical records to ensure compliance with coding regulations, while providing feedback and education to coders and physicians to enhance coding accuracy and documentation quality.

The position involves performing annual, periodic, and focused audits of physician, inpatient, and outpatient coding as requested.

It also requires effective communication with all RAC stakeholders to ensure timely and accurate responses to inquiries.

Additionally, the role supports ongoing program development through training initiatives and process improvements, delivers coding presentations to diverse audiences including physicians and other staff.

The ideal candidate will have at least five years of progressive experience in an acute care hospital setting, including inpatient MS-DRG reimbursement, along with 3–5 years of coding audit or compliance auditing experience.

This includes extensive expertise in inpatient and outpatient auditing (MS-DRGs, CC/MCC validation, POA indicators, PSI/HAC implications), managing external audits (RAC, MAC, OIG, UPIC, commercial payers), and strong knowledge of CMS IPPS/OPPS regulations, OIG Work Plan priorities, Medicare Conditions of Participation, Official Coding Guidelines, NCCI edits, and medical necessity rules.

The candidate should have experience conducting risk assessments, developing audit work plans, quantifying financial impact, presenting findings to leadership, collaborating across CDI, HIM, Revenue Integrity, and Compliance teams, providing provider education, and supporting denials and appeals.

Experience in large or multi-facility health systems, proficiency with encoder and audit software (e.g., 3M, Optum, EPIC) is strongly preferred.

Two years of supervisory experience is required as well as one of the following certifications: CCS, CPC, RHIT/RHIA, CDIP, or CPMA.

• Schedule: 9/80 work schedule - hybrid

• Location: 7898 Mission Grove Parkway, Riverside

This class has been deemed eligible for the Performance Recognition Plan as set forth under Article 3, Section 311 of the County Management Resolution.

Program eligibility requires employees to be in a leadership position, manage other employees or programs and have significant influence on the achievement of organizational objectives.

Every day at Riverside University Health System Medical Center, a dedicated team of healthcare professionals and support staff come together to improve lives across Riverside County.

Our nationally recognized programs and specialized services thrive because of the diverse talents and commitment of our team members.

No matter your background or skill set, you’ll discover meaningful opportunities and a strong sense of purpose here.

To learn more about RUHS Medical Center, please visit www.ruhealth.org

Requirements

Evaluate DRG assignment accuracy and validate principal and secondary diagnoses, procedures, CC/MCC capture, and POA indicators.

Monitor compliance with federal and state regulations, including Medicare, Medicaid, and commercial payer policies.

Assess adherence to documentation standards and identify risk areas related to medical necessity, upcoding, undercoding, and unbundling.

Perform focused audits based on risk assessments, OIG Work Plan priorities, denials trends, and internal compliance initiatives

Collaborate with Clinical Documentation Integrity (CDI), Health Information Management (HIM), Revenue Cycle, and Case Management teams to resolve coding discrepancies and improve documentation quality.

Prepare detailed audit reports outlining findings, root cause analysis, financial impact, and corrective action recommendations.

Educate providers, coders, and revenue cycle staff on regulatory updates, coding changes, audit findings, and compliance risks.

Track audit metrics, monitor corrective action plans, and perform re-audits to ensure sustained compliance improvements.

Support internal investigations and respond to external audit requests (RAC, MAC, OIG, commercial payers).

Maintain knowledge of CMS transmittals, coding clinic updates, and evolving regulatory guidance affecting acute care services.

Contribute to enterprise-wide compliance risk assessments and annual compliance work plan development.

Qualifications

Additional Information