How you make a differenceThe Sr Compliance Coding Auditor performs complex coding audits across a range of services, including those delivered in correctional settings and through third-party billing vendors. This role serves as a subject matter expert on coding and documentation guidelines, identifying risks and preparing detailed audit findings. The position works closely with leadership to develop corrective actions and deliver education to providers and coders. This role also supports regulatory audits and provides guidance and mentorship to compliance staff.
Key Responsibilities- Plan and conduct complex coding audits using risk-based sampling and established methodologies.
- Review provider documentation, coding, and modifier usage to ensure compliance with coding standards and payer rules.
- Analyze findings, prepare detailed audit reports, and present results to providers, coders, and leadership.
- Support corrective action planning, education efforts, and monitoring of compliance trends and regulatory updates.
- Provide guidance to compliance staff and support external audits, vendor oversight, and regulatory inquiries.
Qualifications & RequirementsEducation
- Bachelor's degree in Health Information Management, Healthcare Administration, or a related field preferred
- Associate's degree with substantial equivalent professional coding and auditing credentials and experience may be considered
- Completion of formal coding and/or auditing training program (AAPC, AHIMA, or equivalent) required
Experience
- Minimum five (5) years of progressively responsible experience in professional coding and coding audit
- Demonstrated experience performing complex E/M, primary care, chronic disease management, behavioral health, and/or medication-assisted treatment (MAT) audits using AMA CPT, ICD-10-CM, HCPCS, and CMS guidance
- Experience preparing detailed audit findings reports and presenting results to providers, coders, and operational leadership
- Working knowledge of OIG, CMS, AMA, and payer-specific compliance and documentation requirements
- Experience auditing or overseeing third-party billing vendors strongly preferred
- Familiarity with state Medicaid coding rules, Section 1115 Reentry Demonstration billing requirements, and correctional health workflows strongly preferred
- Previous correctional/detention facility coding or auditing experience preferred
Licenses/Certifications
- Certified Professional Medical Auditor (CPMA) through AAPC - required, and/or
- Certified Professional Coder (CPC) - required, with Certified E/M Coder (CEMC) or Certified Professional Compliance Officer (CPCO) credential strongly preferred
- Certified Professional Biller (CPB) through AAPC - preferred, given the role's emphasis on third-party billing vendor oversight and government-program payer requirements
- Certified Coding Specialist (CCS) through AHIMA may be substituted for an AAPC equivalent
