SUMMARY:Reporting to the Professional Validation Manager, the Coding Quality Reviewer and Educator is responsible for performing comprehensive audits of professional coding and clinical documentation across a multispecialty ambulatory environment. This role validates the accurate assignment of ICD-10-CM, CPT, and HCPCS codes in accordance with CMS regulations, payer policies, organizational standards, and industry guidelines.
This position conducts both prospective and retrospective reviews of provider and coder-selected codes, documents audit findings in a clear, objective, and non-leading manner, and identifies trends, risks, and opportunities for improvement.
Serving as a subject matter expert, the Coding Quality Reviewer and Educator develops and delivers targeted education to coders, providers, and clinical departments to support compliant, defensible documentation and optimal revenue integrity outcomes.
This role requires expert-level coding knowledge, strong analytical and critical thinking skills, and the ability to work independently in a fully remote environment.
RESPONSIBILITIES:- Perform prospective and retrospective audits of professional coding and medical records to validate accuracy and completeness of ICD-10-CM, CPT, HCPCS, and modifier assignment.
- Evaluate clinical documentation to ensure services billed are supported, medically necessary, and compliant with CMS, federal, payer-specific, and organizational requirements.
- Validate both coder and provider assigned codes; document findings, variance details, and supporting rationale in a clear, objective, and audit-defensible format.
- Apply non-leading, compliant review methodologies consistent with ACDIS/AHIMA guidance.
- Identify root causes of coding and documentation discrepancies and collaborate with leadership to develop corrective action plans.
- Develop and conduct targeted education to coders, providers, and clinical departments based on audit findings, coding updates, and identified trends.
- Track and trend audit results to identify systemic risks and opportunities for process improvement.
- Research coding and documentation guidelines from qualified sources, collects relevant information and compiles that information into a user-friendly manual.
- Stays current on coding updates, certification requirements, and expertise pertinent to the position.
Key Skills- ICD-10-CM, CPT, and HCPCS Level II coding guidelines
- E/M coding and/or surgical/procedural coding
- Medical terminology, anatomy, and healthcare documentation
- Knowledge of teaching physician, split/shared visit, and incident-to billing requirements
- Ability to interpret complex medical documentation and apply coding guidelines accurately
- Ability to identify trends, analyze audit data, and recommend process improvement
- Ability to research and apply regulatory guidance from CMS, MAC, and commercial payers.
- Perform detailed audit reviews using standardized audit tools and methodologies
- Communicate complex coding concepts clearly to providers and coders
- Strong attention to detail and organizational skills
- Excellent written and verbal communication skills
- Proficiency with electronic health records (EHR), Epic experience preferred
- Proficiency with Microsoft Office Suite (Word, Excel, PowerPoint)
Compliance & Regulatory Adherence - Maintains expert-level compliance with CMS regulations, National Correct Coding Initiative (NCCI) edits, Medicare Administrative Contractor (MAC) guidance, payer policies, and organizational standards.
- Participate in compliance initiatives to reduce coding-related denials and audit findings.
- Ensures compliance with HIPAA, organizational data privacy, and security policies.
- Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and the American Association of Professional Coders.
Performance Metrics - Meets or exceeds 95% coding accuracy rate
- Achieves productivity benchmarks
- Demonstrates consistent performance in accuracy, timeliness, and workload management
- Adheres to organizational coding guidelines, payer requirements, and documentation standards to support audit readiness and reimbursement integrity
- Accurately audits assigned accounts, responds to inquires, and provides education
- Delivers high-quality education that improves provider documentation and coding performance
MINIMUM QUALIFICATIONS:Education - High school diploma or equivalent required
Certifications One or more of the following required:
- CPC (Certified Professional Coder) - AAPC
- CCS or CCS-P (Certified Coding Specialist / Physician-based) - AHIMA
If applicable, specialty certification in assigned area required within one (1) year of hire.
Experience - Minimum of five (5) years of professional coding experience, preferably in a large academic or multispecialty setting.
- Prior coding audit experience strongly preferred.
- Prior experience performing provider and coder education strongly preferred.
Work Environment Fully Remote: Must maintain a secure, private workspace to protect PHI. Required to use organization-approved secure systems (VPN, multi-factor authentication). Maintains active communication via email, messaging platforms, and attends virtual meetings, as scheduled.
Working conditions: Requires prolonged computer use to review medical records. Ability to meet deadlines while achieving productivity and accuracy standards.
Independent action: Performs independently with minimal supervision and serves as a subject matter expert. Exercises advanced judgment in interpreting coding guidelines and resolving complex issues within the department's policies and practices. Refers specific complex problems to the supervisor when clarification of the departmental policies and procedures are required.
Supervisory responsibility: None
Disclaimer This job description is intended to describe the general nature and level of work performed. Duties and responsibilities may be adjusted based on organizational needs and regulatory requirements.
Pay Range: $67,724.80-$111,716.80
Location:Corporate Headquarters - 15 LaSalle Square Providence, Rhode Island 02903
Work Type:M-F 8:00am-5:00pm
Work Shift:Day
Daily Hours:8 hours
Driving Required:No
