Medical Coding Auditor

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)