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SUMMARY:
Reportingto theProfessional Validation Manager, theCoding Quality Reviewer and Educatoris responsible forperforming comprehensive audits of professional coding and clinical documentation across a multispecialty ambulatory environment. This rolevalidatestheaccurateassignment of ICD-10-CM, CPT, and HCPCS codesin accordance withCMS 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, andidentifiestrends, 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 andoptimalrevenue 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.
Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers and one another.
In addition to our values, all employees are expected to demonstrate the core Success Factors which tell us how we work together and how we get things done. The core Success Factors include:
Instill Trust and Value Differences
Patient and Community Focus and Collaborate
RESPONSIBILITIES:
Perform prospective and retrospective audits of professional coding and medical records tovalidateaccuracy 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.
Validateboth coder and providerassigned 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.
Identifyroot causes of coding and documentation discrepancies and collaborate with leadership to develop corrective action plans.
Develop andconducttargeted education to coders, providers, and clinical departments based on audit findings, coding updates, andidentifiedtrends.
Track and trend audit results toidentifysystemic risks and opportunities for process improvement.
Research coding and documentation guidelines fromqualifiedsources,collectsrelevantinformationandcompilesthat information into a user-friendly manual.
Stays current on coding updates,certificationrequirements, andexpertisepertinent to the position.
Key Skills
Expertknowledge of:
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 tointerpretcomplex medical documentation and apply coding guidelines accurately
Ability toidentifytrends, 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 writtenand verbalcommunication skills
Proficiencywith electronic health records (EHR), Epic experiencepreferred
Proficiencywith 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.
Ensurescompliance with HIPAA,organizational data privacy,and security policies.
Abides by the Standards ofEthical Coding as set forth by the American Health Information ManagementAssociation and the American Association of Professional Coders.
Performance Metrics
Meets or exceeds 95%codingaccuracy rate
Achievesproductivity benchmarks
Demonstratesconsistent performance in accuracy, timeliness, and workload management
Adheresto organizational coding guidelines, payer requirements, and documentation standards to support audit readiness and reimbursement integrity
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, andattendsvirtual meetings, as scheduled.
Working conditions: Requiresprolonged computer useto 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 issueswithin the department’s policies and practices.Refersspecific complex problems to the supervisor when clarification of the departmental policies and procedures arerequired.
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 EEO Statement:
Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.
Location:
Remote-Florida - N/A Tallahassee, Florida 32301 Work Type: