Professional Fee Coding Auditor

PRIMARY FUNCTION

The Professional Fee Coding Auditor is responsible for conducting comprehensive coding audits (prospective and retrospective), ensuring documentation and coding compliance, identifying revenue integrity opportunities, and providing feedback to providers and clinical staff. This role serves as a key partner to physicians, advanced practice providers, operational leaders, and revenue cycle teams to promote accurate coding, documentation integrity, regulatory compliance, and reimbursement optimization. This role ensures compliance with applicable coding guidelines and/or payer requirements as well as regulatory standards while supporting revenue cycle integrity through education and process improvement.

In addition to audit and education responsibilities, this position maintains coding proficiency by performing production coding activities as needed to support business operations, staffing coverage, backlogs, special projects, and organizational priorities.

ESSENTIAL DUTIES AND RESPONSIBILITIES

This list may not include all the duties that may be assigned.

Coding Audit and Compliance

1. Conduct prospective, retrospective, focused, and routine professional fee coding audits for coders, physician and advanced practice provider services of professional fee claims across pediatric private practice settings. Review medical record documentation to validate CPT, ICD-10-CM, HCPCS, modifier assignment, and compliance with applicable payer, federal, and regulatory requirements.
2. Evaluate appropriate modifier usage including modifier 25, 59, 33, 52, and other payer required modifiers.
3. Evaluate documentation for pediatric-specific elements, including growth and development assessments, immunization administration and counseling, age-appropriate screenings, and time-based billing.
4. Complete coding audits in accordance with departmental productivity standards established by audit complexity, project scope, and organizational priorities.
5. Evaluate coding accuracy, documentation sufficiency, medical necessity, and compliance with organizational policies. Maintain audit quality standards with an accuracy rate of 95% or greater while meeting established turnaround times for reporting and education activities.
6. Identify coding trends, risk areas, documentation deficiencies, and revenue leakage opportunities.
7. Monitor provider coding patterns and recommend targeted interventions when opportunities are identified.
8. Support internal compliance initiatives and external audit readiness activities as needed.
9. Maintain knowledge of CMS, Medicare, Medicaid, commercial payer, and regulatory coding requirements.
10. Serve as a trusted coding resource and advisor for physicians, advanced practice providers, and clinical teams.
11. Provide constructive feedback to coders and providers regarding coding accuracy, documentation improvement opportunities, and compliance requirements.
12. Assist with reviewing educational materials, tip sheets, presentations, and coding reference tools as needed.
13. Partner with operational and clinical leadership to address recurring coding and documentation trends.
14. Analyze audit outcomes and coding quality metrics to identify performance improvement opportunities.
15. Track and trend audit results and provider performance metrics.
16. Collaborate with Revenue Cycle, Compliance, Clinical Operations, CDI, and Provider Leadership teams to improve coding accuracy and documentation quality.
17. Participate in departmental quality assurance activities and calibration sessions
18. Ensure coding practices adhere to OIG Work Plan priorities, CMS guidelines, HIPAA, and internal compliance policies.
19. Monitor coding patterns for risk areas, including upcoding, downcoding, unbundling, and modifier misuse.
20. Prepare and maintain detailed audit reports with findings, trend analysis, and recommended corrective actions.

Provider and Staff Education

1. Develop, or assist with, development of targeted education to physicians, advanced practice providers, and coding staff based on audit findings.
2. Create reference materials, tip sheets, and documentation guides specific to pediatric coding scenarios.
3. Support coding improvement with one-on-one or group education sessions with coding staff.

Process Improvement

1. Collaborate with billing and revenue cycle teams to identify root causes of coding-related denials and develop resolution strategies.
2. Assist in developing, updating, and maintaining internal coding policies and procedures for pediatric private practice billing.
3. Track and report key performance indicators, including coding accuracy rates, denial trends, and education outcomes.

QUALIFICATIONS

EDUCATION: Associate's degree in health information management or a related field, or equivalent combination of education and experience may be considered.

EXPERIENCE: Minimum 5 years of professional fee coding experience, with at least 3 years of coding auditing experience in a private practice / medical group environment is required. Experience auditing pediatric nurse practitioner or physician assistant documentation preferred. Experience in multi-specialty group settings where pediatrics operated as a distinct service line preferred.

LICENSURE/ CERTIFICATIONS:

• Active CPC (Certified Professional Coder) and CPMA (Certified Professional Medical Auditor) credentials are required. Both certifications must be current and in good standing.
• Certified Professional Compliance Officer (CPCO) preferred.
• Specialized training or certification in pediatric E/M coding - CPEDC, CRC, or CDEO preferred.

KNOWLEDGE, SKILLS, AND ABILITIES

• Ability to demonstrate experience coding for pediatric outpatient services, including well-child visits, sick visits, immunization administration, and developmental screening.
• Comprehensive knowledge of CPT, ICD-10-CM, HCPCS Level II, E/M documentation guidelines (1995 and 2021 revisions), and payer-specific policies.
• Working proficiency with electronic health record systems.
• Ability to conduct detailed coding audits, identify trends, detect errors, and recommend corrective actions.
• Skill in reviewing provider documentation and translating clinical information into accurate codes.
• Ability to clearly communicate audit findings and provide constructive feedback and training to providers and staff.
• High level of accuracy in reviewing documentation, coding assignments, and audit results.
• Ability to evaluate complex cases, resolve discrepancies, and apply coding guidelines appropriately.

TYPICAL WORKING CONDITIONS

• Non-patient facing
• May be either full time remote/telework or rotate working in the office and remote/telework.
• This job must be U.S. based.
• Indoor work; professional office environment
• Operating computer
• Reach outward.
• May require sitting or standing for long periods, including stooping, bending, stretching.
• Requires occasional lifting of files and boxes weighing up to 25 lbs.
• Manual Dexterity

OTHER PHYSICAL REQUIREMENTS

• Vision
• Sense of sound
• Sense of touch