Job Summary

The PB Coding Auditor is responsible for reviewing and auditing professional fee claims to ensure accurate code assignment, documentation compliance, and adherence to federal, state, payer, and organizational guidelines. This role supports revenue integrity, compliance, and provider education through routine and targeted audits.

Key Responsibilities

• Conduct retrospective and prospective audits of professional billing claims, including E/M services, procedures, modifiers, and diagnosis coding
• Validate coding accuracy against provider documentation, CPT®, HCPCS, ICD-10-CM, and payer-specific rules
• Identify coding errors, trends, and compliance risks, including undercoding, overcoding, and unbundling
• Ensure compliance with CMS guidelines, NCCI edits, LCDs/NCDs, and commercial payer policies
• Provide written audit findings, including clear rationale and corrective action recommendations
• Communicate audit results to providers, coders, and leadership in a professional and educational manner
• Assist with provider and coder education, including one-on-one feedback and training sessions
• Support RAC, MAC, commercial payer, and internal compliance audits as needed
• Collaborate with Revenue Cycle, Compliance, HIM, and Clinical departments
• Maintain audit logs, metrics, and reports for compliance tracking
• Stay current with annual coding updates and regulatory changes

Required Qualifications

• High school diploma or equivalent (Associate’s or Bachelor’s degree preferred)
• 3–5 years of professional fee coding experience
• Demonstrated experience auditing E/M and procedural coding
• Strong knowledge of CPT®, ICD-10-CM, HCPCS Level II, and modifier usage
• Working knowledge of CMS and commercial payer guidelines
• Proficiency with Epic

Required Certifications

One or more of the following: (preferred)

• CPCA (Certified Professional Coding Auditor)
• CPC (Certified Professional Coder)
• CCS-P
• CRC (Certified Risk Adjustment Coder), if auditing risk-based programs

Skills & Competencies

• Strong analytical and critical-thinking skills
• Excellent written and verbal communication
• Ability to provide constructive, educational feedback
• Attention to detail with high accuracy standards
• Ability to work independently and manage multiple audits
• Professional judgment and discretion in compliance matters

Work Environment

• Standard business hours with occasional deadlines related to audit cycles
• Hybrid. Remote/On site