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.
   

PREFERRED QUALIFICATIONS

• Three or more years of medical billing preferred, hospice clinical documentation review, or healthcare compliance auditing experience.
• Direct experience with the Medicare Hospice Benefit and hospice claim requirements.
• Coding or compliance credential such as CPC, CCS, HCS-D, HCS-H, or CHC; clinical licensure (LVN or RN) with hospice experience is also valued.
• Hands-on experience with Netsmart MyUnity.
• Experience responding to TPE, ADR, or UPIC reviews.
• High school diploma or equivalent.

PERFORMANCE EXPECTATIONS:  The following standards define successful performance in this role and will be reviewed at 90 days and annually thereafter.

• Complete pre-bill audit samples on schedule each billing cycle so claim submission is not delayed.
• Maintain audit accuracy such that findings hold up under management review and external audit scrutiny.
• Meet 100% of ADR, TPE, and appeal submission deadlines.
• Deliver the monthly audit summary to leadership by the agreed working day each month.
• Identify and escalate any pattern suggesting systemic billing risk (NOE late filings, F2F misses, cap exposure, level of care concerns) within five business days of discovery.
• Complete assigned compliance and HIPAA training on time and maintain confidentiality standards without exception.
• Demonstrate measurable reduction in repeat documentation and billing errors through education and follow-up over the first year.

WORKING CONDITIONS AND PHYSICAL REQUIREMENTS

• Office environment with prolonged computer and screen use.
• Occasional lifting of records boxes up to 25 pounds.
• Occasional travel between office sites or to training events.
• Work involves regular exposure to confidential patient information; strict adherence to privacy and security policies is a condition of employment.

PRE-EMPLOYMENT
1. Health Screening

2. TB Screening

3. Hepatitis B Series offered

4. Background Check

5. Reference Check

6. Drug Screening

PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to talk, hear, sit, stand, bend at the waist, walk, climb stairs, good manual hand dexterity, reach with hands and arms; and taste or smell. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus. Must be able to drive distances including freeways and mountains when necessary.

WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions. The noise level in the work environment is usually quiet, and conditions are such that are found in an office or hospital and home environment.

We offer a great benefits package to our staff such as:

• Competitive hospice industry compensation
• Benefits package with multiple plan offerings with 100% paid medical, dental, and vision for employees only.
• 401(k) Retirement plan with employer match
• AFLAC insurance plans
• Flexible Spending Account (FSA)
• Fitness Center membership discount
• Employee Assistance Programs (EAP)
• Supportive work culture which encourages work-life balance
• Paid Time Off (PTO)
• Monthly mileage reimbursement
• Employee Referral Program

If you are interested in being part of a dynamic team and helping us continue to be the leader in ensuring the quality of the journey, from a serious illness through 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 encourage you to apply.  To learn more about Hospice of San Joaquin, please visit our website at:  www.hospiceofsanjoaquin.org