Coding Compliance Auditor Job Description

A Coding Compliance Auditor usually arrives after several years working as a hospital or physician practice Medical Coder, and the strongest performers move on from here into Coding Compliance Manager or Compliance Auditing Director roles. Every disputed code eventually lands on this desk. Auditors validate ICD-10-CM/PCS, CPT, and DRG or APC code assignments against AHIMA and CMS guidelines, catching the errors that trigger payer denials. It is close, detail-heavy work that shapes both reimbursement accuracy and the trust providers place in the compliance program, one denial appeal at a time.

You will own the accuracy of coded claims across inpatient and outpatient records, serving as the Coding Compliance Auditor who catches errors before they reach a payer or a compliance review. Coders, clinical documentation staff, and providers all turn to this seat for the final word on a contested code, working alongside the compliance committee that the auditor reports to.

Career Impact: Earning or maintaining a credential like CCS, CPC, or RHIT here signals a level of coding authority that pure coders do not carry.

Business Impact: Every audit finding this role produces protects the organization from denied claims and payer takebacks.

Growth Opportunity: The path from here typically leads to a Coding Compliance Manager or Compliance Auditing Director seat.

• Audit coded claims across inpatient, outpatient, and ambulatory records for accuracy against CPT, ICD-10, and HCPCS guidelines.
• Validate DRG, APC, and severity of illness code assignments against clinical documentation to confirm reimbursement accuracy.
• Report audit findings, coding error trends, and compliance risks to the compliance committee and senior management on a regular schedule.
• Train coders and providers on documentation gaps, coding guideline updates, and physician query best practices.
• Research denied claims from payers and RAC reviewers and prepare appeal rationale grounded in coding guidelines.
• Mentor coding staff through individual feedback sessions on audit results and recurring documentation weaknesses.
• Monitor coder productivity and accuracy rates against departmental quality standards and flag outliers for review.
• Escalate unresolved coding disputes to the reviewer committee and document the final compliance decision.

• Bachelor's degree in health information management, health administration, nursing, or a related clinical field, or equivalent work experience.
• 2 or more years of coding audit experience, with hands-on inpatient and outpatient chart review.
• AHIMA or AAPC coding credential such as CCS, CPC, RHIT, or CIC, held or actively in progress.
• Working knowledge of ICD-10-CM/PCS, CPT, and HCPCS coding systems across inpatient and outpatient settings.
• Strong analytical skills for tracing coding errors and documentation gaps back to their root cause.
• Ability to communicate audit findings clearly and constructively to coders, providers, and management.
• Ability to handle confidential patient, financial, and compliance information with discretion.
• Familiarity with payer denial and appeal processes, including RAC and pre-bill compliance reviews, for disputed coding decisions.

• Working knowledge of DRG, APC, or other prospective payment system reimbursement methodologies and how they affect facility revenue.
• A dedicated auditing credential, such as CPMA or CDIP, held in addition to a base coding certification.
• Experience presenting formal coding education sessions to providers or new coding staff.
• Prior experience within a Level 1 trauma center, academic medical center, or large multi-specialty hospital system.

• Coding accuracy rate per coder, reflecting how closely code assignments match documentation and guidelines.
• Denial appeal overturn rate, showing how well audit rationale holds up with payers.
• Average audit turnaround time in days, measuring how quickly findings reach coders and providers.
• Coder productivity rate, tracking output per coder against departmental volume targets.
• Percentage of audited claims requiring a formal provider query, indicating documentation quality trends over time.

• Base Salary Range: $62,000 to $85,000 per year, varying with hospital size, region, and credentials held
• Bonus: Typically 0 to 5% of base salary, tied to audit performance
• Equity: Not typically offered for this individual contributor role
• Health Benefits: Standard medical, dental, and vision insurance coverage
• PTO: Around 15 to 20 days of PTO annually, plus standard holidays
• Common Perks: Remote or hybrid scheduling, plus tuition or certification exam reimbursement

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

Employment with this organization is contingent on completing a background check and, where applicable, a drug screening, consistent with healthcare industry standards. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, or any other characteristic protected under federal, state, or local law. Reasonable accommodation is available for applicants or employees with disabilities upon request. Candidates must be authorized to work in the United States without current or future sponsorship.

The Coding Compliance Auditor owns coding accuracy audits across physician billing claims, focusing on Coder Quality, Annual Provider, and New Provider reviews to reduce compliance risk. Reporting to the coding manager, the Coding Compliance Auditor partners with billing services, insurance, and customer service representatives to resolve denials and protect reimbursement.

Key Responsibilities

• Perform a variety of audits, including Coder Quality, Annual Provider, Coding Compliance Committee, Integration, and New Provider audits.
• Assess coding accuracy and compliance with policies and procedures and identify areas of potential risk.
• Provide support for the Coding Compliance Committee and Integration Committee through the preparation of summary reports.
• Provide ongoing education to coders and physicians to maximize compliance and reimbursement.
• Represent the billing services and coding departments in on-site meetings and provide support and training for new and established providers.
• Follow coding compliance department standards and branding when communicating with clinical partners and other business center teams.
• Work collaboratively to solve billing and coding issues with billing services, insurance, and customer service representatives.
• Use medical reference resources and contacts to research coding issues and maintain knowledge of payment and reimbursement systems to ensure compliance.
• Analyze coding-related denials and bell curve reports to identify reimbursement deficiencies, coding optimization opportunities, and variation from national averages or peer benchmarks.
• Perform new business coding risk analysis to report on provider coding behaviors that may put revenue and compliance at risk.
• Inspire the trust and respect of the coding team and help increase coder productivity and quality through ongoing education and support.
• Act as a collaborative partner to the coding manager and a resource for billing services managers, practice managers, medical group directors, and system support.

Required Qualifications

• High school diploma or GED required.
• CPC, CCS, or equivalent certification required.
• Auditing certification highly desired.
• 5 or more years of coding and auditing experience within a broader 10-year healthcare background, with extensive payer knowledge.
• Previous interaction with physicians and executive leadership.
• Strong understanding of the healthcare revenue cycle.
• Expert knowledge of ICD-10, CPT, and HCPCS coding systems.
• Strong knowledge of medical terminology, anatomy, and physiology.
• Proficiency in the Microsoft Office suite and Epic software.
• Strong analytical and critical thinking skills, with the ability to anticipate, research, and resolve problems.
• Excellent communication skills, with the ability to communicate accurately, manage interpersonal relationships, and work effectively with clinical partners and business center teams.
• Ability to train and mentor the coding team while building and maintaining positive provider relationships.
• Ability to handle complex and confidential information with discretion.
• Ability to provide excellent customer service, addressing a moderate volume of incoming email and phone calls.

Embedded within the hospital's coding department, the Coding Compliance Auditor carefully builds compliance into every audited chart, resolving complex coding and documentation issues with coders and clinical documentation improvement specialists. Working closely with hospital management, physicians, and coding leadership, the auditor trains new staff, resolves payer denials, and safeguards national and hospital coding guideline compliance.

Core Functions

• Ensure accurate, compliant coding of hospital medical records through training, auditing, and research.
• Work with coders and clinical documentation improvement specialists to resolve complex coding and documentation issues.
• Train and mentor new coding staff and act as a subject matter expert for the coding department, keeping management informed of progress.
• Perform random and focused audits of coded medical records, reviewing charts for coding accuracy, including DRG or APC assignment and severity of illness and risk of mortality levels.
• Check the completeness and accuracy of abstracting, including discharge disposition and present on admission indicators.
• Communicate audit findings to coders and convene a reviewer committee to resolve disagreements, taking accountability for the final coding decision.
• Train and mentor junior coding auditors and trainers by reviewing their work and providing feedback for growth.
• Identify and track coding educational needs based on audit results, and prepare and present training sessions to coders.
• Research and answer coding questions, enlisting the assistance of clinical documentation specialists or management as needed.
• Review coding denials and underpayments from payer audits and provide rationale for appeals.
• Assist with revision of hospital coding guidelines.
• Maintain coding skills by coding and abstracting in accordance with national and hospital coding guidelines.
• Identify, resolve, and escalate major issues and service failures that impede success.

Qualifications & Experience

• Associate's degree in a healthcare-related program.
• Bachelor's degree in a healthcare-related program, or an equivalent combination of education and experience.
• Any AHIMA or AAPC-recognized coding credential required.
• 2 or more years of recent acute care coding auditing and training experience.
• 4 or more years of recent acute care coding experience in hospital inpatient, day surgery, or emergency department settings.
• Track record of troubleshooting coding quality problems.
• Track record of reading and interpreting medical records.
• Track record of organizing and planning, with demonstrated ability to manage time effectively and achieve results.

Reporting to the Compliance Auditing Director, the Coding Compliance Auditor delivers on-site and remote medical record audits, checking CPT, ICD-10, HCPCS, and corporate policy compliance across a variety of medical specialties. Partnering with physician practices and the corporate management team, the auditor prepares compliance reports and delivers provider education based on audit findings.

Primary Duties

• Perform coding audits, reviewing compliance and accuracy with CPT, ICD-10, HCPCS, and corporate coding policy, and follow up for timely completion within a designated time period.
• Maintain thorough documentation of all reviews, methodologies employed, results, corrective actions, and monitoring.
• Assist in focused review projects, including data analysis, reporting, and corrective action identification and roll-out.
• Report findings, identified trends, and risks to the compliance director.
• Participate in departmental meetings and provide compliance knowledge and background as required.
• Assist the compliance director with the development of policies and procedures for the compliance audit program.
• Prepare monthly, quarterly, and annual reports as directed by the compliance director.
• Establish and maintain cooperative working relationships with the management team, physician practices, and staff to provide expertise and compliance training.
• Perform additional administrative duties as assigned by the compliance director or senior management.
• Prepare and present provider education based on preliminary audit findings.

Skills & Qualifications

• CPC certification, or commensurate experience, required.
• CPMA certification required, or willingness to obtain CPMA certification within one year of employment.
• Coding and healthcare background or training required, with a deep understanding of medical chart requirements.
• Prior medical office management experience.
• Strong analytical and organizational skills.
• Ability to set up conference calls and facilitate discussion of audit results.
• Ability to prepare and present provider education based on audit results.
• Ability to exercise initiative, use sound judgment, and employ effective problem-solving techniques in decision-making.
• Self-starter and self-directed, team-oriented, with the ability to meet deadlines.
• Computer skills in word processing, spreadsheets, practice management systems, reporting, and internet research.
• Ability to handle confidential information with the utmost discretion.
• Strong business verbal and written communication skills.

Sitting at the intersection of clinical documentation and coding compliance, the Coding Compliance Auditor ensures accurate ICD-10-CM, ICD-10-PCS, and CPT-4 code assignment across inpatient and outpatient hospital encounters. Operating across trauma, rehabilitation, neurology, and critical care cases, the auditor advises coding specialists, trains new employees, and reports coding quality and productivity for the hospital's coding team.

Duties

• Serve as a clinical coding subject matter expert, analyzing and evaluating documentation issues in consultation with medical, clinical, and clinical documentation staff as needed.
• Audit ICD-10 diagnostic codes and CPT-4 procedure codes for outpatient, ambulatory surgery, and observation visits to support reimbursement, research, and regulatory compliance.
• Audit complex inpatient cases, such as trauma, rehabilitation, neurology, and critical care, using ICD-10-CM and ICD-10-PCS nomenclature to ensure accurate APR-DRG, severity of illness, risk of mortality, and present on admission assignment.
• Serve in an advisory and educator role for coding specialists.
• Serve as the communicator between clinical documentation specialists and coding.
• Research new surgical procedures and technology.
• Provide training to new employees.
• Report coding quality accuracy rates and monitor productivity rates for each coder.
• Conduct specialized focused audits as needed.
• Communicate with various hospital departments regarding coding accuracy and refer problems to management in a timely manner, providing clear details.
• Assist coding specialists in writing appropriate coding queries, working collaboratively with clinical documentation improvement staff on potentially preventable complications and quality indicators.
• Comply with AHIMA standards of ethical coding and coding compliance guidelines.

Requirements

• High school graduate or equivalent required.
• Formal ICD-10-CM, ICD-10-PCS, and CPT-4 training required.
• Associate's or bachelor's degree, with education considered instead of experience.
• Certified Coding Specialist, Registered Health Information Technician, Registered Health Information Administrator, or Certified Inpatient Coder credential.
• 2 or more years of ICD-10-CM and ICD-10-PCS coding.
• Abstracting experience at a Level 1 trauma hospital.
• 4 or more years of experience coding inpatient hospital medical records.
• 2 to 3 years of ambulatory coding experience.

A key member of the hospital's revenue cycle team, the Coding Compliance Auditor leads pre-bill and retrospective coding audits that keep physician documentation, code assignment, and claims processing consistent. Collaborating across physicians, coders, and allied health staff, the auditor improves documentation quality and protects appropriate reimbursement for services provided.

Functions

• Optimize prospective payment reimbursement and facilitate data quality by creating consistency and efficiency in physician documentation, code assignment, data collection, and claims processing.
• Work with physicians, coders, ancillary department staff, clinical documentation improvement staff, and other allied health professionals to improve documentation of patient care and appropriately assign codes or determine charges to support services.
• Perform retrospective random and focused audits of coding cases to ensure accurate code application and overall coding quality.
• Perform pre-bill compliance audits to ensure accurate code assignment, application of coding guidelines, and compliance with external regulatory and accreditation requirements.
• Identify solutions to improve the overall data quality of health records and ensure appropriate reimbursement for services provided.

Experience & Qualifications

• High school diploma, GED, or certificate required, with a bachelor's degree in a related field preferred.
• Certified Coding Specialist (AHIMA), Certified Inpatient Coder or Certified Outpatient Coder (AAPC), or Registered Health Information Technician or Administrator credential required.
• Instead of certification, enrollment in an accredited health information management program with completion of the certification exam within six months of program completion.
• 3 or more years of inpatient or outpatient coding experience, or 5 or more years of experience with 3 or more years of coding auditing experience.
• Past auditing experience or a strong training background in coding and reimbursement preferred.
• Comprehensive knowledge of the Prospective Payment System and other regulatory and payment requirements preferred.

Accurate reimbursement and coding compliance depend on the Coding Compliance Auditor, who builds second-level reviews of diagnosis, procedure, and billing codes against AHA, CMS, and AMA guidelines. Serving as the coding team's technical resource, the auditor researches denials, suggests physician query opportunities, safeguards patient information, and follows AHIMA's ethical coding standards.

Accountabilities

• Perform complex retrospective analysis of medical record documentation to identify coding and billing errors and inconsistencies according to AHA, CMS, AMA, and Coding Clinic and CPT Assistant guidelines.
• Analyze audit findings to identify potential root causes of coding errors and prevent recurrence.
• Provide second-level review of diagnosis, procedure, and billing codes to ensure compliance with legal and procedural policies while adhering to regulations prohibiting unbundling and other questionable practices.
• Research, analyze, and respond to inquiries regarding compliance, inappropriate coding, denials, and billable services.
• Provide technical support and feedback training to internal coding staff regarding coding compliance, documentation, regulatory provisions, third-party payer requirements, and medical necessity requirements.
• Protect the privacy and confidentiality of patient health and client information.
• Follow the Standards of Ethical Coding set forth by AHIMA and adhere to official coding guidelines and compliance practices.
• Suggest physician query opportunities based on documentation and clinical needs.
• Prepare deliverables for coders as required.
• Communicate with coworkers openly and respectfully to promote teamwork and knowledge sharing.
• Provide a schedule of planned work activities, events, and sites, with any changes, to management and staff.
• Maintain professional coding credentials and knowledge of coding, reimbursement methodologies, and compliance issues through ongoing education.

Technical Qualifications

• Recognized coding credential from AHIMA or AAPC required.
• Registered Health Information Administrator or Technician credential may also be considered.
• Experience with telecommuting and electronic medical records systems strongly preferred.
• 5 to 7 or more years of experience coding or auditing in an acute care facility or clinic.
• Strong analytical skills.
• Excellent written communication skills.
• Strong team player, with the ability to work with multiple and diverse clients and projects.
• Ability to work with minimal supervision.

Coding Compliance Auditor delivers risk-based coding quality audits of inpatient and outpatient encounters, validating code assignment against official coding guidelines and clinical documentation in the health record. The work directly supports accurate facility reimbursement by reviewing ICD-9, ICD-10, MS-DRG, and APC data while creating clear audit reports for coders and directors.

Operational Focus

• Understand, interpret, and apply coding guidelines for coding audits.
• Audit inpatient and outpatient encounter code assignments, reviewing medical records to determine coding accuracy of documented diagnoses and procedures.
• Review claims to validate submitted codes and abstracted data, including ICD-9 and ICD-10-CM and PCS codes, MS-DRGs, CPT codes, APCs, and discharge disposition affecting facility reimbursement.
• Create clear and accurate audit findings and recommendations in written audit reports for coders, auditors, managers, and directors.
• Identify documentation issues, such as lacking documentation or missed physician queries, that affect coding accuracy.
• Communicate opportunities for documentation improvement related to coding issues, verbally and in written reports or summaries.
• Stay current with AHA Official Coding and Reporting Guidelines and CMS and other agency directives for ICD-9 and ICD-10-CM and PCS and CPT coding, completing online education and attending mandatory coding workshops and seminars.
• Review AHA and CPT quarterly coding update publications.
• Attend internal conference calls for quarterly coding updates.
• Validate abstracted data elements integral to appropriate payment methodology.

Knowledge, Skills & Abilities

• Knowledge of disease pathophysiology and drug utilization.
• Knowledge of MS-DRG classification and reimbursement structures.
• Knowledge of APC, OCE, and NCCI classification and reimbursement structures.
• Ability to consistently and accurately audit coding of inpatient and outpatient encounters.
• Knowledge of medical terminology, ICD-9 and ICD-10 CM/PCS, evaluation and management, and CPT-4 coding guidelines and methodologies.
• Computer knowledge of Microsoft Office.
• Ability to create clear and concise audit reports while maintaining productivity standards.
• Detail-oriented, with the ability to work independently.
• Ability to demonstrate initiative and discipline in time management and assignment completion.
• Ability to work in a virtual setting under minimal supervision.
• Must successfully pass a pre-hire coding assessment.
• Ability to travel and work in a sitting position for extended periods, using a computer, keyboard, and mouse, including driving to off-site locations and walking through hospital-based departments as needed.