Role Overview

Conduct audits and reviews of medical records for coding accuracy, documentation compliance, and reimbursement integrity, with a primary focus on ProFee coding (ICD-10-CM, CPT, HCPCS, modifiers).
Perform or support hands-on coding as needed, including ProFee coding assignments and related coding quality reviews.
Review coding for appropriate code selection, diagnosis linkage, modifier usage, medical necessity, and documentation support.
Audit E/M coding (when applicable) to ensure accurate level assignment and provider documentation support.
Support auditing/coding functions for facility services (outpatient and/or inpatient) as needed; facility coding/auditing experience is preferred.
Ensure compliance with federal, state, payer-specific, and client-specific regulations and policies, including CMS guidelines.
Assignment of ICD-10-CM diagnosis code based on ICD-10-CM Official Guidelines for Coding and Reporting along with UHDDS standards
Assignment of CPT/HCPCS procedure code based on organizational policy/procedures/guidelines and AMA
Assignment of Evaluation and Management (E/M) code base on organizational policy/procedures/guidelines and AMA
Identify coding/documentation discrepancies, trends, and risk areas; recommend corrective actions and process improvements.
Prepare clear audit reports summarizing findings, education points, error trends, and recommendations.
Provide feedback and education to coders and/or leadership regarding coding guidelines, documentation requirements, and audit outcomes.
Collaborate with operations, HIM, billing, and other relevant teams to resolve findings and support compliance.
Monitor follow-up and corrective actions resulting from audits to ensure issues are addressed timely.
Stay current on coding guideline updates, payer policy changes, regulatory requirements, and industry best practices.
Assist in developing and refining audit tools, quality review processes, policies, and procedures.
Adhere to organizational and client coding guidelines, productivity standards (if applicable), and confidentiality requirements.

Requirements

Associate’s degree in Health Information Management or related field preferred (or equivalent combination of education and experience).
3–5+ years of coding experience required, including professional fee (ProFee) coding.
Coding audit experience required (internal QA, audit, compliance review, or similar).
Facility coding and/or facility audit experience preferred (outpatient and/or inpatient).
Strong knowledge of ICD-10-CM, CPT, HCPCS, modifiers, and documentation requirements.
Working knowledge of payer guidelines, CMS regulations, NCCI edits, and medical necessity principles.
Experience auditing and/or coding E/M services preferred (if applicable to client scope).
Strong analytical skills, attention to detail, and ability to identify coding trends and root causes.
Effective written and verbal communication skills, including the ability to provide constructive audit feedback and education.
Proficiency with EHR/EMR systems and coding/auditing tools (e.g., Epic, Cerner, encoder tools, payer portals).
Certifications Required (one active coding credential): CPC, CCS, COC, or CIC
Preferred: CPMA (Certified Professional Medical Auditor) RHIT, RHIA CCS CDIP Certified Professional Medical Auditor (CPMA)

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Medical Coding Auditor