Coding Auditor Job Description

Medicare and Medicaid reimbursement rules tie every claim to the accuracy of its ICD-10-CM, ICD-10-PCS, and CPT/HCPCS codes, and CMS scrutinizes discrepancies through DRG, APC, and HCC risk adjustment reviews. Someone has to catch the errors first. The auditor reviews charts only after coders have closed them, looking for patterns across dozens of cases that a single denial or appeal would never surface. Findings from these reviews inform provider education and protect revenue integrity across every specialty the organization bills for, since a single missed pattern can trigger a much larger payer recoupment.

Success as a Coding Auditor means catching the coding and documentation errors that would otherwise cost the organization revenue, trigger a payer audit, or misrepresent a patient's risk profile. The work is done independently, chart by chart, with findings reported back to coding management and the providers whose documentation shaped each code.

Career Impact: Every audit sharpens the credentials that already anchor this work, from CCS and CPC to RHIA and RHIT, building a reputation that regulators and providers both trust.

Business Impact: Catching a miscoded DRG or an unsupported HCC diagnosis before a payer does protects revenue the organization would otherwise have to return.

Growth Opportunity: Auditors who master risk adjustment and DRG methodology typically move into coding compliance leadership or HCC program oversight positions.

• Audit closed inpatient, outpatient, ambulatory surgical, and professional charts for ICD-10-CM, ICD-10-PCS, and CPT/HCPCS coding accuracy.
• Validate DRG, APC, and HCC risk adjustment code assignments against official CMS coding and reporting guidelines.
• Prepare formal audit findings reports and present the results to coders, providers, and coding management.
• Guide providers through documentation gaps found during chart review to raise coding specificity and completeness.
• Identify recurring coding and documentation error patterns across coders and recommend corrective action plans.
• Monitor coding and regulatory updates, including annual ICD-10 and quarterly CMS guideline changes, to keep audit criteria current.
• Escalate unresolved compliance risks and suspected fraud or abuse indicators to the compliance department.
• Support coding education sessions that translate audit findings into practical documentation improvement guidance.

• Bachelor's degree in health information management, health information technology, or a related field, or equivalent work experience.
• 2 or more years of medical coding experience, with prior chart auditing or quality review experience preferred.
• Active coding credential, such as Certified Coding Specialist, Certified Professional Coder, RHIA, RHIT, or CDEO.
• Thorough knowledge of ICD-10-CM, ICD-10-PCS, and CPT/HCPCS coding classification systems and official coding guidelines.
• Working knowledge of CMS coding guidelines and Medicare, Medicaid, and commercial payer reimbursement and billing rules.
• Strong verbal and written communication skills for delivering coding feedback to providers and coders.
• Ability to work independently while managing multiple concurrent audits, deadlines, and competing priorities.
• Proficiency with standard office software and electronic medical record systems used in chart review.

• Bachelor's degree in health information management, health information administration, or a closely related academic field.
• Prior experience auditing the coding work of other coders and providing structured feedback for improvement.
• Experience with Medicare HCC risk adjustment coding and its supporting clinical documentation and validation requirements.
• Experience presenting audit findings or leading formal coding education sessions for providers and coding staff.

• Charts reviewed per week or per pay period, reflecting the pace of the review workload.
• Coding error rate identified per audit cycle, measuring how many discrepancies surface.
• Corrective action plans completed on time, tracking follow-through on audit findings.
• Provider education sessions delivered per quarter, measuring outreach on documentation gaps.
• Turnaround time from chart review to reported findings, measured in business days.

• Base Salary Range: $55,000 to $75,000 per year, depending on certification and audit specialization
• Bonus: Occasional annual performance bonus, typically 2 to 5 percent of base salary
• Equity: Equity is uncommon for this role outside larger health system corporate structures
• Health Benefits: Standard medical, dental, and vision coverage, often with employer-subsidized premiums
• PTO: Typically 15 to 20 paid time off days annually, plus standard holidays
• Common Perks: Remote or hybrid schedules, tuition assistance, and continuing education reimbursement are common

Figures are estimates based on general US market benchmarks and may be outdated. Adjust based on location, company size, and seniority level.

Background checks and, where applicable, drug screening are required before employment in this healthcare setting. Reasonable accommodation under the Americans with Disabilities Act is available upon request during the application or employment process. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, disability, veteran status, or any other characteristic protected under federal, state, or local law. Employment is contingent on verified authorization to work in the United States.

The Coding Auditor delivers accurate diagnosis and procedure coding across emergency, surgical, and inpatient facility records, sequencing codes correctly for APC, MS-DRG, and APR-DRG assignment. Reporting to Facility Coding Services, the Coding Auditor validates Computer-Assisted Coding assignments and reviews documentation to protect coding accuracy and revenue integrity across the health system.

Key Responsibilities

• Assign accurate diagnosis and procedure codes to patient health records across emergency, surgical, observation, and inpatient facility records.
• Sequence principal diagnosis and procedure codes for proper APC, MS-DRG, and APR-DRG assignment using applicable coding conventions.
• Validate Computer-Assisted Coding assignments for dual coding accuracy.
• Perform chart analysis to identify incomplete, inaccurate, or inconsistent documentation.
• Review medical records to ensure diagnostic and therapeutic procedures conform to CMS coding rules and guidelines.
• Communicate with physicians to obtain clarification on diagnoses and procedures.

Required Qualifications

• Coding Specialist Certificate, Registered Health Information Administrator Certificate.
• Registered Health Information Technician Certificate.
• 2 or more years of experience in a directly related coding field, or 18 months in an apprenticeship program.
• Advanced knowledge of disease processes, diagnostic and surgical procedures, and applicable government coding regulations.
• Demonstrated knowledge of CMS HCC risk adjustment coding.
• Advanced knowledge of ICD-10-CM, ICD-10-PCS, and HCPCS/CPT classification systems.
• Strong time management, organizational, and analytical skills.

Embedded within the regulatory compliance and revenue integrity practice, the Coding Auditor delivers inpatient, outpatient, and professional coding validation services for hospital, behavioral health, and long-term care clients, auditing for coding quality, accuracy, and guideline compliance. Working closely with client coding staff and engagement teams, the Coding Auditor researches billing and coding issues, documents audit findings, and provides technical guidance that protects clients from compliance risk.

Core Functions

• Provide inpatient, outpatient, and professional coding validation services to clients across hospital, behavioral health, and long-term care settings.
• Perform on-site and off-site coding validation reviews for quality, accuracy, and compliance with established guidelines.
• Research billing and coding issues and document findings with referenced regulatory guidance.
• Provide coding methodologies, guidance, and technical leadership for engagement teams.
• Interview stakeholders to understand project workflow, policy, and procedure controls.
• Establish or interpret project objectives, scope, budgets, and timelines in coordination with engagement teams.

Qualifications & Experience

• Bachelor's degree, preferred.
• RHIA or RHIT certification, preferred, with additional CCS, CPC, CCS-P, or CCS-H certification preferred or obtainable within one year.
• 2 or more years of coding experience, including MS-DRG and APC coding knowledge.
• Knowledge of Medicare, Medicaid, and commercial payer coding and billing rules and regulations.
• Thorough knowledge of ICD-10-CM and CPT/HCPCS coding classification systems.
• Intermediate knowledge of Microsoft Office Suite, including Excel, Word, and PowerPoint.
• Strong analytical, presentation, and client relationship skills.

Reporting to the compliance department, the Coding Auditor leads retrospective and concurrent coding audits across inpatient and outpatient records, assessing documentation accuracy for DRG and APC quality reviews. Partnering with providers and coding staff, the Coding Auditor resolves documentation issues and delivers audit findings that support the hospital's revenue enhancement and compliance goals.

Primary Duties

• Perform retrospective and concurrent coding audits based on established coding guidelines to ensure accuracy and proper reporting.
• Prepare and present pre-bill and retrospective audit reports directly to providers and coders.
• Analyze coded data to identify areas of risk and recommend documentation improvements.
• Interact with providers and coding staff to resolve documentation or coding issues.
• Respond to coding questions from assigned coders and providers, citing official coding references and guidelines.
• Report compliance and risk issues to the compliance department.

Skills & Qualifications

• High school diploma required, with an associate's or bachelor's degree preferred.
• 5 or more years of professional coding experience, with 2 or more years as a coding quality auditor preferred.
• In-depth knowledge of ICD-10-CM/PCS and CPT coding principles, including DRG, APC, and modifier assignment.
• Working knowledge of human anatomy, physiology, and disease processes.
• Proficiency in Microsoft Office applications, including Word and Excel.
• Excellent verbal and written communication skills.

Sitting at the intersection of centralized coding oversight and practitioner education, the Coding Auditor builds accurate ICD-10, CPT, and HCPCS coding practices for a multi-specialty medical group, validating charge capture against CMS guidelines and organizational policy. Operating across ambulatory and outpatient practice sites, the Coding Auditor partners with leadership to strengthen HCC and other risk adjustment capture through targeted provider and coder education.

Duties

• Perform medical record audits, including analysis of documentation and validation of primary and secondary diagnoses and procedures.
• Ensure proper assignment of diagnosis and procedure codes using CMS coding guidelines.
• Monitor the accuracy of centralized coders' charge capture and coding, including modifier assignment.
• Partner with leadership to improve HCC and other risk adjustment capture through provider and coder education.
• Conduct ongoing reviews of medical record documentation and procedural and diagnosis coding by each practitioner.
• Provide practitioner education on coding, documentation, and compliance.

Requirements

• High school diploma or equivalent required.
• Certified Professional Coder, Registered Health Information Technician, CRC.
• Certified Documentation Expert Outpatient credential required.
• 2 or more years of professional coding experience.
• 3 or more years of prior auditing experience preferred.
• Comprehensive knowledge of ICD-10, CPT, and HCPCS modifiers required.
• Knowledge of Medicare, Medicaid, and other third-party billing rules and regulations.
• Solid understanding of ICD-10 and CPT coding and medical terminology.
• Effective verbal, written, and interpersonal communication skills for working with diverse populations.
• Ability to maintain accurate records and exercise independent judgment within standard practices and procedures.

A key member of the coding management team, the Coding Auditor reviews health risk evaluations to assign ICD-10 codes that are clinically supported and compliant with CMS guidelines. Collaborating across coding staff and group leadership, the Coding Auditor identifies and corrects coding problems while applying Medicare risk adjustment protocol to support accurate claims payment.

Functions

• Review health risk evaluations within required timelines to determine completion and compliance with CMS guidelines.
• Assess the accuracy, completeness, specificity, and appropriateness of diagnosis codes identified in health risk evaluations.
• Assign ICD-10 codes that are clinically identified and supported in each assessment.
• Communicate with coding management and group leaders regarding issues or corrections.
• Identify, correct, and report coding problems.
• Make recommendations for coding policy changes.

Experience & Qualifications

• High school diploma or equivalent required, with an associate's or bachelor's degree preferred.
• Certified Coding Associate, Certified Coding Specialist, Certified Coding Specialist for Providers, or Certified Professional Coder credential preferred, current and maintained during employment.
• 1 or more years of ICD-10 coding experience, with prior healthcare coding experience preferred.
• Experience and knowledge of Medicare HCC coding.
• Advanced knowledge of medical terminology, anatomy and physiology, major disease processes, and pharmacology.
• Good verbal and written communication skills.

Coding, billing, and documentation accuracy depends on the Coding Auditor, who audits a defined number of records per coder against the organization's coding audit plan and reports findings to key stakeholders. Serving as an internal resource for coding education, the Coding Auditor develops corrective action plans and presents training programs that address high-risk billing and compliance areas.

Accountabilities

• Audit a specified number of records per coder as defined in the coding audit plan.
• Prepare audit reports and issue them to key stakeholders as appropriate.
• Develop corrective action plans to address coding, billing, and documentation improvement opportunities.
• Identify trends and educational opportunities from audit findings.
• Prepare and present educational programs related to coding.
• Assist in managing the coding and billing auditing and monitoring program for high-risk compliance areas.

Technical Qualifications

• Certified Coding Specialist, Certified Professional Coder, Registered Health Information Administrator.
• Registered Health Information Technician credential from AHIMA or AAPC.
• High school diploma or GED with 2 years of experience, or an associate's or technical degree, required.
• 1 or more years of experience required, with 3 to 5 years of clinic coding experience strongly preferred.
• Strong evaluation and management coding knowledge and leveling experience preferred.
• Excellent communication skills.

As the Coding Auditor, this role reviews medical records and coding to validate DRG results, schedules and performs on-site audits, and documents findings in the audit workflow system. The audit program relies on this work to render coding decisions on appeals and escalate unresolved facility issues to management for resolution.

Activities

• Review medical records and coding to validate clinical coding accuracy.
• Enter required DRG review information into the encoder program to obtain a validated DRG.
• Identify questionable encoder results and review them with the program manager.
• Schedule and perform onsite audits in accordance with program policies and procedures.
• Review appeal information and render a coding decision to uphold or overturn the original finding.
• Escalate facility issues to management for resolution.

Position Requirements

• High school diploma required.
• Certified Coding Specialist or Certified Professional Coder credential required.
• 2 to 5 or more years of inpatient hospital coding experience with ICD-10-CM/PCS and MS-DRG.
• 5 years of DRG auditing experience.
• Registered Health Information Technician or Registered Health Information Administrator certification.
• Good verbal and written communication skills.

Coding Auditor leads quality reviews of colleague-coded data, delivering completed audits with educational feedback to each coder and their supervisor to maintain high accuracy standards under Arizona Medicaid guidelines. The work directly supports quality assurance by investigating client coding questions and monitoring colleague error trends to guide targeted educational sessions.

Operational Focus

• Review colleague-coded data to ensure quality standards and provide educational feedback to the colleague.
• Provide completed audits with feedback to the colleague and their supervisor.
• Hold conference calls with colleagues and supervisors to discuss audit questions as needed.
• Investigate client coding quality assurance questions regarding colleague-coded charts.
• Monitor and interpret colleague error trends to provide expert feedback during educational sessions.

Knowledge, Skills & Abilities

• AAPC certification required.
• 2 or more years of professional auditing experience.
• Strong evaluation and management coding and surgical coding background.
• Knowledge of Arizona Medicaid guidelines.
• Experience with electronic medical record systems.
• Demonstrated ability to maintain a high level of accuracy under pressure while multitasking in a dynamic environment.

The Coding Auditor oversees professional coding and billing accuracy across multiple departments, reporting on procedure, E/M, and ICD-10 coding compliance with payer, legal, and procedural policy. Reporting to compliance and revenue cycle leadership, the Coding Auditor educates providers and staff on accurate documentation, coding guidelines, and reimbursement rules to reduce billing risk.

Key Deliverables

• Review and audit professional coding and billing from multiple departments and entities.
• Report on the accuracy of procedure, E/M, and ICD-10 coding and billing to ensure compliance.
• Review billing and revenue cycle processes for accuracy and process improvements.
• Identify inaccurate coding practices and prepare findings reports for providers and medical office staff.
• Conduct education and training for department and clinical staff on documentation and coding guidelines.
• Provide education on reimbursement rules, regulations, and health insurance processing requirements.

Professional Experience

• AHIMA- or AAPC-recognized certification, such as CPC, CCS, RHIA, or RHIT, required, plus 4 or more years of coding, clinical, or billing experience.
• Demonstrated human relations and effective communication skills, with proficiency in medical terminology.
• Proficiency with computer software such as Microsoft Word and Excel, including data manipulation.
• Experience and understanding of federal regulations and payer policies, with the ability to interpret information.
• Problem-solving skills with the ability to identify and analyze root causes.

Embedded within the enterprise quality assurance program, the Coding Auditor produces first-level quality audits on vendor and internal coding teams' results across multiple markets. Working closely with coding teams across markets, the Coding Auditor applies coding guidelines consistently, identifies issues and trends affecting accuracy, and shares feedback on audit results.

Areas of Ownership

• Assist with execution of the daily activities of the enterprise quality assurance program.
• Perform first-level quality audits on vendor coding results.
• Perform first-level quality audits on internal coding teams' results.
• Support coding initiatives across markets, including concurrent review and query compliance audits.
• Ensure coding guidelines are consistently applied across all processes.
• Identify issues and trends in coding and documentation that affect coding accuracy.

Background & Experience

• High school education or equivalent experience required.
• Coding certification required, such as CPC, CCS, CCS-P, or RHIT.
• 4 or more years of recent ICD-9/10 coding experience with a strong, high accuracy rate.
• 2 or more years of recent Medicare risk adjustment (HCC coding) experience.
• 1 or more years of recent experience in a coding auditor role, auditing the work of other coders and providing feedback.
• Proficient knowledge of the CMS-HCC model and guidelines.