Professional Fee Coding Auditor Claims Edit Specialist (Full-Time, Day)

At NorthBay Health the Professional Fee Coding Auditor is responsible for auditing professional fee coding across all service lines (Ambulatory/Hospitalist, Surgery, and Emergency Medicine), resolving pre‑billing coding edits, and reviewing post‑billing coding‑related denials.

This role ensures coding accuracy, documentation integrity, and compliance with CPT, HCPCS, ICD‑10‑CM, and payer‑specific rules. The position supports coding quality improvement, identifies trends, provides coder feedback and physician education based on audit and edit findings, and partners with leadership to strengthen coding workflows across the organization.

PRIMARY JOB DUTIES

Audit Responsibilities

- Performs routine and targeted professional fee coding audits across all service lines: Ambulatory/Hospitalist (including Urgent Care and Pools), Surgery, and ED ProFee.
- Reviews documentation for completeness, accuracy, and compliance with CPT, HCPCS, ICD‑10‑CM, and payer policies.
- Identifies trends, patterns, and recurring issues affecting coding quality or compliance.
- Prepares audit summaries and provides clear, constructive feedback to coders and leadership.
- Assists in developing coder and physician education based on audit findings.

Pre‑Billing Edit Resolution

- Reviews and resolves coding‑related edits in pre‑bill work queues within the current EHR/coding platform.
- Validates CPT/HCPCS, ICD‑10‑CM, and modifier accuracy to ensure clean claims prior to billing.
- Escalates documentation deficiencies to providers using established query processes.
- Identifies edit trends and recommends workflow or rules‑based improvements.

Post‑Billing Denials Review

- Reviews coding‑related denials and determines appropriate corrective action.
- Provides coding clarification for Billing, Revenue Integrity, and Denials teams.
- Tracks denial trends and collaborates with leadership to reduce recurrence.

Coder and Physician Education

- 13. Develops and delivers targeted coder education based on audit findings, pre bill/PB edit trends, and denial trends.
- 14. Identifies documentation or coding patterns requiring physician level education, and coordinates with the Manager & Supervisor, Professional Coding, and/or Medical Staff leadership to schedule and deliver physician education as needed.
- 15. Prepares education materials (tip sheets, presentations, case examples) reflecting current CPT, HCPCS, ICD 10 CM, and payer guidance.
- 16. Measures the effectiveness of education provided by tracking improvement in subsequent audit, edit, and denial findings .

Compliance & Quality

- Ensures all work complies with CMS, AMA, OIG, payer policies, and NorthBay standards.
- Maintains strict confidentiality and HIPAA compliance.
- Supports continuous improvement of coding workflows and audit processes.

Professional Standards

- Performs other duties as assigned.

Education :

- High School diploma preferred; Associate’s or Bachelor’s preferred.

Certification:

- Requires one of the following credentials: CPC, CCS-P, or CPMA.
- CRC (Certified Risk Adjustment Coder) preferred in addition to one of the certifications above.

Experience:

- Minimum 5 years of professional fee coding experience across multiple specialties.
- Minimum 3 years of prior auditing and edit‑resolution experience is required.
- Strong knowledge of anatomy, physiology, medical terminology, disease processes, and official coding guidelines.

Skills :

- Requires strong analytical skills, deep understanding of clinical documentation, and the ability to work independently with high accuracy in any EHR or coding/billing platform.
- Proficiency with EHRs, encoders (e.g., 3M), and Microsoft Office.

Interpersonal Skills :

- Communicates effectively with coders, providers, and cross‑functional teams.
- Maintains professionalism under deadlines and shifting priorities.

Standards of Performance:

- Demonstrate performance by adhering to established policies and procedures and exhibiting the defined characteristics associated with attendance and punctuality.

Physical Effort:

- Attendance is an essential function of the job. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions

Ability to sit for extended periods.
- Ability to lift/push/pull up to 5 lbs.
- Frequent keyboarding and sustained concentration.