Position: Coding Compliance Specialist
Reports To: Operations Director
Exempt/Non: Exempt, Full-Time
Education: CPC (Certified Professional Coder) required; CPMA (Certified Professional Medical Auditor) preferred; CCS (Certified Coding Specialist) preferred
Experience: Minimum of five (5) years of physician and/or facility coding experience
The Coding Compliance Specialist is responsible for ensuring coding accuracy, regulatory compliance, and adherence to federal, state, payer, and organizational coding standards. This position serves as the department's subject matter expert for coding compliance by conducting internal and external audits, researching evolving coding regulations, supporting payer audit activities, and developing organizational coding and compliance standards.
This role is a complementary role to the Coding Operations Specialist, which focuses on operational workflow and production. The Coding Compliance Specialist focuses on compliance-related coding review.
In addition to audit responsibilities, the Coding Compliance Specialist leads the research and development of coding and compliance frameworks for prospective clients by evaluating specialty-specific coding requirements, documentation standards, payer regulations, and operational considerations to support successful client onboarding and implementation.
This position is an individual contributor role and does not include direct supervisory or personnel management responsibilities.
- Demonstrated expertise in coding audits, regulatory compliance, and coding research
- Thorough knowledge of ICD-10-CM, CPT, HCPCS, CMS regulations, payer policies, and official coding guidelines
- Strong analytical, research, and problem-solving skills
- Excellent written and verbal communication skills
- Proficiency with electronic health records (EHR), coding software, and Microsoft Office application
- Conduct routine internal coding audits to evaluate coding accuracy, documentation quality, and compliance with ICD-10-CM, CPT, HCPCS, CMS, and payer guidelines
- Review external audit findings and validate recommended corrections prior to releasing encounters from audit hold queues
- Perform annual coding audits for designated clients to ensure ongoing coding accuracy and regulatory compliance
- Document audit findings, identify coding and documentation trends, and recommend educational opportunities to improve coding quality
- Monitor compliance with applicable federal regulations, payer policies, and organizational coding standards
- Identify compliance risks and recommend corrective actions and process improvements
- Track audit metrics and prepare audit summaries for leadership review
- Research evolving CMS regulations, payer policies, coding updates, and industry guidance affecting coding and reimbursement
- Develop, maintain, and update internal coding and compliance policies, standards, reference materials, and best practice guidelines
- Create and revise coding appeal letter templates, compliance documentation, audit tools, certification letter templates, and supporting resources to promote departmental consistency
- Translate regulatory changes into practical guidance and educational resources for coding staff
- Maintain departmental coding reference libraries and compliance resources
- Help identify payer denials that could be resolved through education of proper coding guidelines
- Research coding, documentation, regulatory, and payer requirements for prospective clients across multiple medical specialties
- Develop specialty-specific coding and compliance frameworks to support the successful onboarding of new client contracts
- Evaluate payer requirements, specialty coding guidelines, and documentation expectations to establish compliant operational workflows for new business opportunities
- Collaborate with operational leadership during the implementation of new client coding processes
- Assist in developing coding policies, workflows, and documentation standards for newly acquired clients
- Collaborate with physicians and providers to prepare certification letters and supporting documentation for payer audits and medical record reviews
- Support clients with payer coding and contractual issues by researching applicable regulations, identifying coding requirements, and presenting findings to facilitate appropriate resolution
- Assist with coding-related audit responses, compliance inquiries, regulatory documentation requests, and payer appeals as needed
- Serve as a coding compliance resource during external audits and client reviews
- Serve as the primary resource for coding staff regarding coding guidelines, compliance issues, payer policies, and documentation requirements
- Provide coding guidance based on current regulatory standards and official coding references
- Share audit findings, coding trends, and regulatory updates with the Operations Director to support ongoing education and quality improvement initiatives
- Assist in developing educational materials and coding reference tools for internal staff
- Coding Compliance
- Medical Coding Auditing
- Regulatory Research
- Policy and Standards Development
- Documentation Review
- Coding Quality Assurance
- Critical Thinking
- Analytical Problem Solving
- Written and Verbal Communication
- Collaboration and Consultation
- Attention to Detail
- Organization and Time Management
- Professional Judgment
- Adaptability
- Ability to sit and work at a computer for extended periods
- Ability to occasionally lift up to 20 pounds
- Maintain confidentiality of protected health information in accordance with HIPAA regulations
- Maintain required coding certifications and continuing education requirements
- Participate in departmental meetings, compliance initiatives, and special projects as assigned
- Support departmental and organizational compliance initiatives
- Perform other duties as assigned
