Compliance Audit Specialist

The Compliance Audit Specialist conducts medical record reviews and other audits to monitor for compliance with internal policies and external regulations. S/he assists in implementation of the Quality and Compliance Management Program including the development of policies and procedures and implementation of compliance training.
Position Details

Education Required: Registered Nurse (RN) license, current
Work Location: Community Hospice and Palliative Care main location; 4265 Sunbeam Road, Jacksonville, FL. No work from home at this time.
Days/Hours: Monday - Friday 8:00am - 5:00pm
Compensation: Commensurate with experience; full benefits package including 23 days annual PTO


Job Responsibilities
Performs medical records reviews for services provided by the agency to ensure compliance with regulatory requirements, including, but not limited to, documentation requirements and appropriateness of care.

Assist with audit design.
Independently completes medical record reviews and audits within
Consults with agency staff for clarification of clinical data. Facilitates and improves organization staff’s understanding of payor and regulatory requirements by providing feedback related to documentation.

Processes additional documentation request received from Medicare, Medicaid and third-party payors to ensure compliance and the maximization of appropriate organization reimbursement.

Conducts medical record reviews related to additional documentation requests.
Identifies potential denials and works with organization staff to strengthen documentation where appropriate.
Coordinates the additional documentation request process including maintenance of tracking logs and preparation of cover letters as required.
Provides updates/reports to the Director of Quality and Risk Manager regarding the status of additional documentation requests.

Participates in review of claims denied by Medicare, Medicaid and third-party payors to ensure both compliance and the maximization of appropriate organization reimbursement.

Assists with the medical record reviews related to denials and documents findings.
Prepares appeals for denial when appropriate based on the review of medical records or coverage criteria, including preparation of appeal templates, forms, and cover letters, as required.
Coordinates the appeals process including maintenance of tracking mechanisms throughout the review process to a final determination.
Prepares reports for the Risk Manager and Director of Quality regarding the status of open denials and appeals.
Participates in the development and implementation of identified improvements to systems/procedures related to reasons for claim denials.

Investigates, responds to, and communicates information regarding documentation, compliance, and reimbursement questions.

Compiles and analyzes data.
Supports, provides analysis for, and advises management regarding documentation issues.
Analyzes documentation issues/questions from a compliance perspective.
Develops and implements a system for documenting and communicating responses to all compliance questions.


Identifies and communicates educational needs based on clinical record audits and other regulatory audits to the Director of Quality and/or appropriate compliance team member.

Assists in developing and providing compliance education to organization staff, including clinical documentation and regulatory changes.

Provides accurate and up-to-date information on regulatory requirements.
Provides expertise for compliance issues.
Assists in the development of compliance education materials.
Prepare reports and graphics for presentations.
Maintains attendance lists for all presentations and logs of issues raised and identified for future research and response.


Maintains current knowledge of industry regulations, issues and best practices and ensures appropriate dissemination and communication of changes to the appropriate members of the Compliance Department.

Participates as an active member of agency committees as assigned, including attending meetings and reporting on projects and findings as requested. Participates in Team Rounding to patient care teams to solicit feedback and/or provide regulatory updates and education.

Assists management with special projects and performs other duties as may be required to support the organization’s compliance program

Education & Experience Needed

Registered Nurse (RN) licensure, state of Florida.


Bachelor’s degree preferred, in nursing and/or business-related field.
Three to five (3 to 5) years on-the-job experience in healthcare auditing, medical chart review, healthcare consulting, insurance company/intermediary, or may consider clinical experience.


Desired Knowledge, Skills, and Abilities

Demonstrated proficiency with applicable laws and regulations including Medicare, Medicaid, and other third-party payors.
Proficiency in reading medical records.
Knowledge of general research methods, including, but not limited to, research of health care regulatory requirements.
Ability to evaluate medical necessity using governmental regulatory and private payor guidelines and nursing judgment.
Ability to solve practical problems and exercise independent judgment in planning work details and making technical decisions related to audits.
Must be detail oriented with strong organizational and multi-tasking skills to meet scheduled deadlines.
Previous hospice work experience preferred.