Revenue Cycle Auditor - Credentialed Coder

Overview

The Revenue Cycle Auditor – Credentialed Coder is responsible for end to end auditing of professional and facility claims to ensure accurate, complete, and compliant coding and billing. This role partners closely with revenue cycle leadership, coding teams, and clinical providers to identify root causes of denials, drive best practices in claims resolution, and deliver targeted education that improves documentation quality and reimbursement accuracy.

The ideal candidate brings deep working knowledge of ICD 10 CM/PCS, CPT®, and HCPCS Level II, along with hands on experience using NCCI/CCI edits, MUEs, and payer policies across inpatient, outpatient, and professional settings.

• Audit & Compliance
  • Perform prospective and retrospective audits of medical records and associated charges to validate code selection, modifiers, medical necessity, and documentation sufficiency across inpatient, outpatient, ED, and professional services.
  • Evaluate claims against NCCI/CCI edits, MUEs, payer bulletins, and internal policy; document findings and corrective actions to ensure regulatory and payer compliance.
  • Conduct focused and random provider audits (including multi specialty) and maintain defensible audit work papers, scoring, and feedback summaries.
  • Coordinate audit response process including all RAC audits, CERT Reviews and DRG-related downcodes or recoupments.

• Denials Prevention & Resolution
  • Analyze denial trends related to coding, medical necessity, bundling, modifier usage and collaborate with coding, billing, and clinical teams to implement preventive edits and workflow improvements.
  • Support appeal strategy by drafting or refining coding based appeal rationales and by supplying documentation evidence aligned to payer guidelines.

• Education & Best Practices
  • Develop and deliver education for coders, billers, providers, and residents on compliant documentation and coding, emerging code set updates, and payer policy changes.
  • Provide one on one and group feedback sessions, translating audit results into practical job aids, tip sheets, and specialty specific guidance.

• Operational Excellence
  • Partner with IT and revenue cycle teams to optimize edits, charge capture, and reconciliation processes; contribute to policy and procedure updates that enhance accuracy and throughput.
  • Track and report KPIs (accuracy rate, denial rate, appeal overturns, audit completion cadence, education impact) and recommend continuous improvement initiatives.

• Active CPC® (AAPC) or equivalent coding credential (e.g., CCS, CCS-P, COC); commitment to ongoing CEUs.
• 10+ years of broad coding/auditing experience spanning inpatient, outpatient, emergency department, and professional services; demonstrated competency in multispecialty environments (e.g., cardiology, OB/GYN, pediatrics and pediatric subspecialties, neurology, nephrology, GI, pulmonary, critical care, urology, behavioral health).
• Proficiency with ICD 10 CM/PCS, CPT®, HCPCS Level II, NCCI/CCI edits, MUEs, medical necessity standards, and payer policy interpretation.
• Proven experience auditing claims, resolving denials, preparing appeals, and educating providers/coding staff.

• Familiarity with Cerner, E Clinical Works, Epic or similar EHR/PM/coding tools; proficiency with Microsoft Word, Excel, and PowerPoint.
• Exposure to charge reconciliation, posting reviews, and collaboration with revenue integrity/IT for edit design and workflow optimization.

• Regulatory & Compliance Acumen:
  Up to date on coding guidelines, payer rules, and audit standards; meticulous documentation and evidence handling.
• Analytical Problem Solving:
  Trend analysis for denials/root causes; converts findings into process improvements and measurable outcomes.
• Education & Communication:
  Skilled at translating complex coding concepts into clear, actionable guidance for clinicians and staff.
• Collaboration:
  
  Works cross functionally with coding, billing, providers, revenue integrity, and IT to sustain best practices.