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Coding Compliance Specialist

Prestige Billing Services, Ltd.
Miamisburg, OH

Quick Apply

Job Details

Full-time
4 days ago

Qualifications

CMS
Medical coding experience in physician offices
Certified Professional Coder
CMS regulatory compliance
Quality assurance audits
Medicare regulations
Clinical information systems
Desktop applications
Centers for Medicare & Medicaid Services (CMS) billing regulations
Productivity software
Quality audits

Full Job Description

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.

Requirements (Skills & Background)

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

Essential Duties and Responsibilities

Coding Compliance and Auditing

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

Regulatory Research and Standards Development

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

New Client Compliance and Research

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

Audit and Payer Support

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

Coding Consultation and Education

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

Core Competencies

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

Physical Requirements

Ability to sit and work at a computer for extended periods
Ability to occasionally lift up to 20 pounds

Additional Responsibilities

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

Quick Apply

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