Compliance Analyst

El Camino Health Medical Network is currently seeking a talented Compliance Analyst to join our growing healthcare team!

Pay : $104,000-$114,400 Annually (Exempt)

Location :Los Gatos, CA (Hybrid-Must be Local)

Summary: The Compliance Analyst monitors and evaluates coding, billing, and documentation practices to ensure alignment with federal and state regulations, payer policies, and internal standards. The role supports risk mitigation, conducts investigations, and partners with clinical and operational teams to improve compliance across the medical network.

Essential Functions: Regulatory Monitoring and Interpretation

• Track and interpret regulatory changes affecting professional services, including CMS, OIG, AMA CPT, and commercial payer policies.
• Assess the impact of new rules on coding, billing, and documentation workflows.
• Develop guidance and compliance alerts to communicate regulatory updates to stakeholders.

Professional Coding and Billing Compliance Review

• Conduct internal audits of CPT, HCPCS, and ICD‑10‑CM coding for professional services across multiple specialties.
• Review E/M services for correct level selection, time‑based coding, and medical decision‑making alignment.
• Evaluate modifier usage, medical necessity, and documentation sufficiency.
• Identify trends in errors, denials, and potential compliance risks.

Investigations and Risk Mitigation

• Support investigations related to billing irregularities, payer inquiries, and potential fraud, waste, or abuse.
• Collaborate with legal, compliance, and revenue cycle teams to develop corrective action plans.
• Assist in preparing responses to payer audits, including documentation requests and appeals.

Data Analysis and Reporting

• Analyze coding and billing data to identify patterns, anomalies, and areas of risk.
• Prepare compliance dashboards, audit summaries, and performance reports for leadership.
• Monitor key indicators such as denial trends, coding accuracy rates, and audit outcomes.

Compliance Program Support

• Develop and deliver training on professional fee compliance, COI, Stark, AKS, and general compliance expectations.
• Maintain documentation of audits, investigations, and corrective actions in accordance with compliance program standards.
• Support risk assessments, internal reviews, and external audits by providing data, analysis, and subject‑matter expertise.
• Contribute to policy development and updates related to billing, physician arrangements, and organizational compliance.
• Partner with coders, providers, practice managers, and revenue cycle teams to resolve compliance issues.
• Support development of policies and procedures related to coding, billing, and documentation compliance.

Minimum Requirements:

• High School Diploma or equivalent. Bachelor’s degree in Business, Healthcare Administration, or similar field preferred.
• AAPC credentials such as CPC, CPMA, or CPCO.
• Experience in compliance, auditing, or revenue cycle operations within a physician practice or health system.
• Familiarity with federal regulations such as Medicare billing rules, OIG guidance, and state‑specific requirements.
• Strong analytical skills with the ability to interpret clinical documentation and billing data.
• Excellent communication skills, especially in explaining complex regulatory concepts.

Other Knowledge, Skills, And Abilities:

• Experience with multi‑specialty professional coding audits.
• Background in denial management, payer appeals, and compliance investigations.
• Knowledge of risk adjustment, quality reporting, and reimbursement methodologies (e.g., RBRVS).
• Experience developing compliance education or training materials.

The Compliance Analyst monitors and evaluates coding, billing, and documentation practices to ensure alignment with federal and state regulations, payer policies, and internal standards. The role supports risk mitigation, conducts investigations, and partners with clinical and operational teams to improve compliance across the medical network.

Essential Functions: Regulatory Monitoring and Interpretation

• Track and interpret regulatory changes affecting professional services, including CMS, OIG, AMA CPT, and commercial payer policies.
• Assess the impact of new rules on coding, billing, and documentation workflows.
• Develop guidance and compliance alerts to communicate regulatory updates to stakeholders.

Professional Coding and Billing Compliance Review

• Conduct internal audits of CPT, HCPCS, and ICD‑10‑CM coding for professional services across multiple specialties.
• Review E/M services for correct level selection, time‑based coding, and medical decision‑making alignment.
• Evaluate modifier usage, medical necessity, and documentation sufficiency.
• Identify trends in errors, denials, and potential compliance risks. Investigations and Risk Mitigation
• Support investigations related to billing irregularities, payer inquiries, and potential fraud, waste, or abuse.
• Collaborate with legal, compliance, and revenue cycle teams to develop corrective action plans.
• Assist in preparing responses to payer audits, including documentation requests and appeals.
• Data Analysis and Reporting
• Analyze coding and billing data to identify patterns, anomalies, and areas of risk.
• Prepare compliance dashboards, audit summaries, and performance reports for leadership.
• Monitor key indicators such as denial trends, coding accuracy rates, and audit outcomes.
• Compliance Program Support
• Develop and deliver training on professional fee compliance, COI, Stark, AKS, and general compliance expectations.
• Maintain documentation of audits, investigations, and corrective actions in accordance with compliance program standards.
• Support risk assessments, internal reviews, and external audits by providing data, analysis, and subject‑matter expertise.
• Contribute to policy development and updates related to billing, physician arrangements, and organizational compliance.
• Partner with coders, providers, practice managers, and revenue cycle teams to resolve compliance issues.
• Support development of policies and procedures related to coding, billing, and documentation compliance.

Other Knowledge, Skills, And Abilities:

• Experience with multi‑specialty professional coding audits.
• Background in denial management, payer appeals, and compliance investigations.
• Knowledge of risk adjustment, quality reporting, and reimbursement methodologies (e.g., RBRVS).
• Experience developing compliance education or training materials.