Coding Denials Auditor

The Coding Denials Auditor is responsible for reviewing, auditing, and accurately coding inpatient, outpatient, and professional claims to ensure proper reimbursement, compliance with billing regulations, and adherence to coding standards. This role collaborates with revenue cycle teamsand serves as a subject matter expert on coding practices, with a special focus on claim denials and appeals.

Position: Coding Denials Auditor / Medical Coder

Work Setup: Full-Time, Onsite

Coding Accuracy (ICD-10, CPT, PCS)

Analytical & Problem Solving

Key Responsibilities

Conducts coding audits of submitted claims to determine appropriateness of procedure and diagnosis codes billed based on documentation provided for inpatient and outpatient facility claims as well as professional claims.

Reviews billing for accuracy to ensure compliance of proper billing and coding procedures of third-party carriers and to ensure complete and accurate reimbursement.

Coordinates with revenue cycle teams to investigate rejected or denied claims to determine denial accuracy and work in an inter-departmental collaboration process to assist in claim corrections/appeals.

Collaborates with other senior coders (and the other coding staff) with sharing coding information and providing coding advice to colleagues regarding complex cases to be coded.

Effectively utilizes computer and appropriate software (Microsoft Office Suite) to produce correspondence, charts, spreadsheets and/or other information applicable to the position assignment, including a basic to intermediate level of competency in Excel which is required.

Applies knowledge of anatomy and physiology, clinical disease processes, pharmacology, and diagnostic and procedural terminology to determine the appropriate assignment of ICD-10-CM diagnosis codes, including sequencing, and CPT-4 applications to abstract clinical documentation for advanced documentation appeals of physician/professional, ancillary, emergency department, outpatient surgery, clinic visits and injections.

Reviews patient records for accuracy in ICD-10-CM/PCS, DRG assignment, present on admission indicators (POA), discharge disposition and any other pertinent data needed to capture coding accuracy. Applied knowledge of medical terminology, pathophysiology, and pharmacology to assist in accurate MS-DRG assignment and appeals.

Mentors other coders during their orientation period and assists them in understanding policies, procedures, and coding concepts.

Serves as a resource and subject matter expert regarding accurate and ethical coding and documentation standards and professionally shares information to both internal and external stakeholders.

Assists manager with special projects/other tasks as assigned.

Communicates with senior leadership to ensure critical issues are addressed.

Maintains knowledge regarding medical coding and/or healthcare market changes.

Other duties as required.

Must Have

Current certification in one of the following:

Certified Professional Coder (CPC) – AAPC

Proficient knowledge of ICD-10, PCS, CPT, HCPCS, medical terminology, and disease processes.

2+ years of experience in inpatient, outpatient, or physician coding.

Strong background in billing/coding, including AR, EOBs, and revenue cycle management.

Experience managing coding denials and preparing appeals.

Knowledge of Medicare, Medicaid, and Commercial payer guidelines.

Analytical, problem-solving, and research skills.

Time management skills and ability to work independently.

Experience with CAC/Encoder audits and code selection from audit findings.

Nice to Have

Experience with multiple fee schedule concepts (DRGs, APCs, NCCI).

Familiarity with healthcare documentation systems.

Strong verbal, interpersonal, and customer service skills.

Ability to communicate complex audit outcomes to medically and non-medically oriented staff.

Veterans’ Administration and MVA medical billing/coding experience. #J-18808-Ljbffr