Billing Compliance Auditor

Hospice of San Joaquin is the oldest not-for-profit hospice of over 45 years. We serve all of San Joaquin and Stanislaus Counties. We are committed to continuing to be the leader in ensuring the quality of the journey, from a serious illness through the end of life, and to honor our mission by honoring life by ensuring patients and their Caregivers are the focus of everything we do. We are seeking a Dynamic, self-motivated Billing Compliance Auditor who thrives in a fast-paced environment and supports our mission.

POSITION SUMMARY
The Billing Auditor is responsible for auditing hospice claims, clinical documentation, and billing workflows to confirm that services billed to Medicare, Medi-Cal, and commercial payers are supported by the medical record and meet all regulatory requirements. The position bridges the clinical and financial sides of hospice operations. The auditor must read clinical documentation with enough depth to judge eligibility and level of care support, must understand hospice coding and the technical mechanics of hospice billing, and must work comfortably inside Netsmart MyUnity and related electronic systems. Findings from this position protect the organization from claim denials, payment recoupment, and regulatory exposure, and they drive education back to clinical and billing staff.

ESSENTIAL DUTIES AND RESPONSIBILITIES
Pre-Bill and Post-Bill Claim Auditing

• Perform pre-bill audits on a defined sample of claims each billing cycle, verifying that each claim is supported by the certification, plan of care, visit documentation, and physician orders before submission.
• Conduct post-payment audits and trend analysis to identify documentation gaps, coding patterns, and billing errors that create denial or recoupment risk.
• Verify level of care billing (Routine Home Care, Continuous Home Care, General Inpatient, and Inpatient Respite) against the clinical record, including hour thresholds for continuous care and documentation supporting GIP necessity.
• Reconcile visit documentation in MyUnity against billed services to confirm dates, disciplines, and units match the record.

Eligibility and Certification Audit

• Audit timeliness and completeness of the Notice of Election (NOE) and Notice of Termination or Revocation (NOTR), including the five-day filing requirement and exception documentation when deadlines are missed.
• Verify certification and recertification of terminal illness for each benefit period, including physician narrative requirements and signature timeliness.
• Audit face-to-face (F2F) encounter compliance for the third benefit period and beyond, confirming the encounter occurred within the required window and that attestation requirements are met.
• Track benefit period sequencing and election status to prevent billing outside an active election.

Coding and Documentation Review

• Review ICD-10-CM diagnosis coding on hospice claims for accuracy, specificity, and proper sequencing of the principal diagnosis and related conditions.
• Confirm that diagnoses billed are consistent with the certification narrative, the comprehensive assessment, and the plan of care.

Audit Response and Regulatory Support

• Track audit deadlines, submission status, and outcomes; coordinate appeals documentation when claims are denied.
• Monitor the hospice aggregate cap and per-beneficiary utilization data, flagging exposure early in the cap year.
• Stay current on CMS hospice regulations, MAC guidance (Noridian for California), the annual hospice final rule, and OIG work plan items affecting hospice billing.

Reporting and Education

• Produce monthly audit summaries with error rates, dollar impact, root causes, and corrective action status for leadership committee.
• Develop and deliver targeted education to clinical, intake, and billing staff based on audit findings.
• Maintain audit work papers, sampling methodology, and findings documentation in an organized, defensible format.
• Ability to read a clinical chart critically and connect documentation to billing requirements.
• Strong analytical skills, attention to detail, and the ability to organize large volumes of records under deadline.
• Clear written and verbal communication, including the ability to explain audit findings to clinicians without an accusatory tone.
• Discretion in handling protected health information in accordance with HIPAA and organizational policy.

TECHNICAL AND COMPUTER SKILLS

• Netsmart MyUnity preferred: navigating the clinical record, running reports, reviewing claims and billing batches, and tracing documentation from assessment through claim.
• Microsoft 365: strong Excel skills (pivot tables, lookups, basic data cleanup) for audit sampling and trend reporting; Outlook, Word, SharePoint, and Teams for daily work.
• Comfort learning new software quickly and documenting repeatable processes for others.