Coding Compliance Auditor

JOB TITLE: Coding Compliance Auditor

REPORTS TO: Director of Billing and Credentialing

FLSA STATUS: Non-Exempt

JOB SUMMARY

The Coding Compliance Auditor is responsible for conducting ongoing audits of provider documentation, coding accuracy, and revenue integrity to ensure compliance with federal and state regulations, payer guidelines, and internal policies. This role evaluates clinical documentation and coding practices to reduce risk, improve reimbursement accuracy, and support continuous compliance and quality improvement initiatives across the organization.

QUALIFICATIONS / EDUCATION

• Associate or Bachelor’s degree in Health Information Management, Healthcare Administration, Nursing, or related field preferred.
• Minimum 2–3 years of experience in medical coding, auditing, or revenue cycle compliance required.
• Strong knowledge of CPT, ICD-10-CM, HCPCS, and modifier usage.
• Knowledge of Medicare, Medicaid, and commercial payer guidelines.
• Experience auditing E/M services, procedures, and documentation in a clinical setting.
• Proficiency with EHR systems and coding/audit software.
• Bilingual English/Spanish preferred.

CERTIFICATIONS / LICENSES

One or more of the following preferred (or required based on policy):

• CPC (Certified Professional Coder)
• CCS (Certified Coding Specialist)
• CRC (Certified Risk Adjustment Coder)
• CPMA (Certified Professional Medical Auditor)
• CCA (Certified Coding Associate)

ABILITIES / SKILLS

• Strong analytical and auditing skills with high attention to detail.
• Ability to interpret clinical documentation and coding regulations accurately.
• Excellent written and verbal communication skills.
• Ability to work independently and manage multiple audits simultaneously.
• Strong organizational and time-management skills.
• Ability to maintain confidentiality and work with sensitive provider and patient information.
• Professional, objective, and ethical judgment.

SUPERVISORY RESPONSIBILITIES

N/A

ESSENTIAL DUTIES / RESPONSIBILITIES

Coding & Documentation Audits

• Conduct routine and focused audits of provider documentation and coded services to ensure compliance with CPT, ICD-10, and HCPCS standards.
• Review medical records for completeness, accuracy, and appropriate medical necessity.
• Identify trends in undercoding, overcoding, and documentation gaps.
• Ensure compliance with CMS, OIG, and payer-specific requirements.

Revenue Integrity & Risk Mitigation

• Evaluate coding practices for revenue integrity and reimbursement accuracy.
• Detect and report potential compliance risks and billing vulnerabilities.
• Assist in preventing denials, recoupments, and payer audits through proactive review.
• Support corrective action plans and follow-up audits.

Education & Provider Feedback

• Provide written audit findings and recommendations to providers and billing staff.
• Educate providers and coding teams on documentation and coding improvements.
• Participate in training initiatives related to regulatory updates and best practices.

Reporting & Process Improvement

• Prepare audit reports summarizing findings, error rates, and corrective actions.
• Track audit results and compliance trends over time.
• Recommend process improvements to enhance documentation quality and coding accuracy.
• Collaborate with Billing, Credentialing, Compliance, and Clinical Leadership teams.

Compliance Support

• Support internal and external audits as needed.
• Maintain audit documentation and evidence according to compliance standards.
• Stay current on coding and regulatory changes impacting reimbursement and compliance.

Additional Responsibilities

• Participate in revenue cycle and compliance meetings as assigned.
• Perform other duties as assigned by the Director of Billing and Credentialing.