Medical Records Audit SME

2 days ago

India Zealie Full time

**This is a Remote Position**

About Zealie

Zealie is a fast-growing Medical Billing Services company specializing in the Behavioral Healthcare industry. Our clients include substance use disorder treatment, addiction recovery, and mental health treatment centers that save lives every day. Our proprietary technology provides data analytics and revenue prediction tools that empower clients to make strategic business decisions and grow their organizations.

We are committed to delivering exceptional products and services, and our Medical Records Audit team plays a critical role in achieving this mission. We are seeking a Subject Matter Expert (SME) in the Medical Records Audit Team to provide advanced expertise, training, and strategic guidance that ensures compliance, accuracy, and payer alignment across the department.

Job Summary:

The Audit Team Subject Matter Expert will support and function within the Medical Records Department. The ideal candidate will be responsible for ensuring the accuracy, completeness, compliance, and confidentiality of health records. This role is critical in maintaining documentation standards, supporting regulatory audits, and ensuring adherence to legal and accreditation requirements (e.g., HIPAA, Joint Commission, CMS). This position requires strong departmental functioning knowledge and in-depth understanding of complexities related to Medical records and documentation for Behavioral Health Services.

Responsibilities and Duties

  • Conduct reviews of medical records charts to ensure accuracy, completeness, consistency, and compliance with healthcare guidelines & regulations, and organizational policies.
  • Review clinical documentation for regulatory compliance (e.g., CMS, Joint Commission, HIPAA) and support external audit readiness.
  • Identify discrepancies, documentation gaps, or potential risks in health record maintenance and documentation practices.
  • Develop and maintain audit tools, checklists, training materials, and SOPs for consistent audit practices.
  • Train and educate staff on documentation standards, electronic health record (EHR) usage, and audit best practices.
  • Monitor updates to state and federal medical record regulations and translate those changes into department policies.
  • Create Spreadsheet for Retrospective Review Letters and follow Retrospective Review letter setup/Process Guidelines
  • Prepare detailed reports and dashboards summarizing audit results, trends, and recommendations for leadership.
  • Support initiatives for improving documentation quality and medical record management processes.
  • Lead training sessions and workshops for staff on documentation standards and audit preparedness
  • Perform additional duties as requested by direct Supervisors and/or Management.

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