Essential Duties and Responsibilities

Coding Compliance and Auditing

• Conduct routine internal coding audits to evaluate coding accuracy documentation quality and compliance with ICD-10-CM CPT HCPCS CMS and payer guidelines
• Review external audit findings and validate recommended corrections prior to releasing encounters from audit hold queues
• Perform annual coding audits for designated clients to ensure ongoing coding accuracy and regulatory compliance
• Document audit findings identify coding and documentation trends and recommend educational opportunities to improve coding quality
• Monitor compliance with applicable federal regulations payer policies and organizational coding standards
• Identify compliance risks and recommend corrective actions and process improvements
• Track audit metrics and prepare audit summaries for leadership review

Regulatory Research and Standards Development

• Research evolving CMS regulations payer policies coding updates and industry guidance affecting coding and reimbursement
• Develop maintain and update internal coding and compliance policies standards reference materials and best practice guidelines
• Create and revise coding appeal letter templates compliance documentation audit tools certification letter templates and supporting resources to promote departmental consistency
• Translate regulatory changes into practical guidance and educational resources for coding staff
• Maintain departmental coding reference libraries and compliance resources
• Help identify payer denials that could be resolved through education of proper coding guidelines

New Client Compliance and Research

• Research coding documentation regulatory and payer requirements for prospective clients across multiple medical specialties
• Develop specialty-specific coding and compliance frameworks to support the successful onboarding of new client contracts
• Evaluate payer requirements specialty coding guidelines and documentation expectations to establish compliant operational workflows for new business opportunities
• Collaborate with operational leadership during the implementation of new client coding processes
• Assist in developing coding policies workflows and documentation standards for newly acquired clients

Audit and Payer Support

• Collaborate with physicians and providers to prepare certification letters and supporting documentation for payer audits and medical record reviews
• Support clients with payer coding and contractual issues by researching applicable regulations identifying coding requirements and presenting findings to facilitate appropriate resolution
• Assist with coding-related audit responses compliance inquiries regulatory documentation requests and payer appeals as needed
• Serve as a coding compliance resource during external audits and client reviews

Coding Consultation and Education

• Serve as the primary resource for coding staff regarding coding guidelines compliance issues payer policies and documentation requirements
• Provide coding guidance based on current regulatory standards and official coding references
• Share audit findings coding trends and regulatory updates with the Operations Director to support ongoing education and quality improvement initiatives
• Assist in developing educational materials and coding reference tools for internal staff

Core Competencies

• Coding Compliance
• Medical Coding Auditing
• Regulatory Research
• Policy and Standards Development
• Documentation Review
• Coding Quality Assurance
• Critical Thinking
• Analytical Problem Solving
• Written and Verbal Communication
• Collaboration and Consultation
• Attention to Detail
• Organization and Time Management
• Professional Judgment
• Adaptability

Physical Requirements

• Ability to sit and work at a computer for extended periods
• Ability to occasionally lift up to 20 pounds

Additional Responsibilities

• Maintain confidentiality of protected health information in accordance with HIPAA regulations
• Maintain required coding certifications and continuing education requirements
• Participate in departmental meetings compliance initiatives and special projects as assigned
• Support departmental and organizational compliance initiatives
• Perform other duties as assigned