Performs retrospective and concurrent audits of medical coding, clinical documentation, DRG assignments, and regulatory compliance. Reviews denials, supports appeals, identifies coding and documentation risks, prepares audit findings, tracks trends, and educates coding and clinical stakeholders to improve accuracy, compliance, reimbursement, and audit readiness.
Job Summary
The Compliance Coding Auditor performs independent audits of coded medical records to evaluate accuracy, documentation integrity, and compliance with coding guidelines, regulatory requirements, and organizational policies. This role supports coding compliance and revenue integrity through audit activities, denial review and appeal support, and identification of documentation and coding risks. The Compliance Coding Auditor collaborates with coding, clinical, and revenue cycle stakeholders to improve coding accuracy, support audit readiness, and promote consistent application of coding standards across the organization.
Essential Functions
The Compliance Coding Auditor performs independent audits of coded medical records to evaluate accuracy, documentation integrity, and compliance with coding guidelines, regulatory requirements, and organizational policies. This role supports coding compliance and revenue integrity through audit activities, denial review and appeal support, and identification of documentation and coding risks. The Compliance Coding Auditor collaborates with coding, clinical, and revenue cycle stakeholders to improve coding accuracy, support audit readiness, and promote consistent application of coding standards across the organization.
Essential Functions
- Performs retrospective and concurrent coding audits to assess accuracy, completeness, and compliance with ICD-10-CM/PCS, CPT/HCPCS, DRG, and applicable regulatory requirements.
- Reviews clinical documentation to ensure alignment with coded data, including evaluation of present on admission (POA), discharge disposition, and medical necessity.
- Conducts denial reviews and validates coding and documentation to support appeal processes and reimbursement outcomes.
- Develops and prepares audit findings, including detailed documentation and appeal rationale supported by clinical and coding guidelines.
- Identifies coding and documentation trends, risks, and opportunities for improvement, and communicates findings to appropriate stakeholders.
- Provides feedback and education to coding staff and leadership based on audit results to improve accuracy and compliance.
- Maintains audit tracking, reporting, and documentation of findings, trends, and resolution activities.
- Performs other duties as assigned.
- Maintains regular and reliable attendance.
- Complies with all policies and standards.
- H.S. Diploma or GED required
- Associate Degree in Health Information Management or related field preferred
- 2-4 years in Health Information Management or related field required
- 2-4 years of coding audit, denial management, or compliance review experience preferred
- Experience with DRG validation, payer audits (e.g., RAC, commercial), and appeal processes preferred
- Knowledge of coding classification systems, DRG methodologies, and regulatory requirements, including Medicare Prospective Payment Systems.
- Knowledge of clinical documentation standards, disease processes, pathophysiology, and pharmacology as it relates to accurate code assignment.
- Ability to perform detailed coding audits and interpret clinical documentation to support compliant coding and reimbursement.
- Ability to analyze audit findings, identify trends, and develop actionable recommendations to improve coding quality and reduce denials.
- Ability to prepare clear, well-supported audit reports and appeal documentation.
- Ability to communicate effectively with coding, clinical, and operational stakeholders regarding audit findings and recommendations.
- CCS-Certified Coding Specialist required or
- RHIT - Registered Health Information Technician required or
- RHIA - Registered Health Information Administrator required
- CDIP - Clinical Documentation Improvement Professional preferred
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