Coding Audit Manager

Description

Core Clinical Partners stands at the forefront of Emergency and Hospital Medicine, delivering unparalleled services through a model that emphasizes patient-centric care and operational excellence. Our corporate values – Genuine, Accountable, Dynamic, Respectful, and Fun – are the pillars that uphold our commitment to revolutionize healthcare delivery.

The Manager, Coding Audit reviews and analyzes denied claims related to coding and documentation issues and oversees Core’s clinician auditors. This role ensures accurate medical coding in compliance with federal regulations and payer-specific guidelines, identifies denial trends and root causes, and reduces future occurrences. The Coding Audit Manager collaborates closely with coding staff, revenue cycle teams, and clinical departments to resolve issues, appeal denials, and support the organization's financial health.

Essential Duties: 

 Denial Analysis & Resolution:

• Review and analyze coding denials, including CPT, ICD-10-CM, and HCPCS-related denials, to identify root causes and coding-related trends. 
• Identify recurring denial patterns and implement corrective actions to reduce future denials and improve coding accuracy. 
• Collaborate with billing, revenue cycle, and clinical teams to research and resolve coding discrepancies and denial issues. 
• Conduct audits of medical records to ensure coding accuracy, documentation support, and compliance with regulatory and payer requirements. 

Reporting & Denial Trending:

• Develop and maintain regular reporting on coding-related denials, including denial volumes, denial reasons, financial impact, trends, and resolution outcomes. 
• Summarize findings from coding denial reviews and communicate key issues, trends, and opportunities for improvement to leadership and operational teams. 
• Track recurring coding errors and identify opportunities for coder education, provider education, workflow improvements, or process changes. 
• Monitor the effectiveness of corrective actions and provide follow-up reporting to ensure identified issues are resolved. 

Payor Denial Crosswalk Development:

• Develop and maintain a coding denial crosswalk by payer to identify common denial reasons, payer-specific coding requirements, and applicable CPT, ICD-10-CM, and HCPCS coding issues. 
• Document payer-specific denial patterns and requirements to support consistent denial resolution and prevention strategies. 
• Use the denial crosswalk to identify trends across payers and prioritize education, audits, and corrective actions. 
• Partner with internal teams to ensure the crosswalk remains current as payer policies, edits, and denial trends evolve.

Productivity & Performance Monitoring:

• Monitor coding productivity and quality metrics to identify performance trends, opportunities for improvement, and potential workflow barriers. 
• Analyze coder productivity in conjunction with denial and quality findings to identify opportunities for education, process improvement, and workload optimization. 
• Develop and maintain productivity reporting to track individual and team performance against established goals and benchmarks. 
• Identify trends impacting productivity, including workflow inefficiencies, system issues, documentation challenges, and payer-specific requirements. 
• Provide feedback and recommendations to leadership regarding productivity performance, staffing needs, workflow improvements, and operational efficiencies.

 Appeals Management:

• Prepare and submit comprehensive appeal letters with supporting documentation.
• Ensure appeals are submitted within payer-specific timeframes.
• Track and document the status of appeals until resolution.

Compliance & Documentation:

• Maintain up-to-date knowledge of coding guidelines, payer policies, and regulatory requirements.
• Ensure all coding and billing activities comply with HIPAA and other relevant regulations.
• Document all denial and appeal activities accurately in the system.

 Reporting & Communication:

• Generate reports on denial trends and appeal outcomes for management review.
• Communicate effectively with internal departments and external payers to resolve issues.
• Provide feedback, training, and best practices for coding staff based on findings from denials.
• Perform other related duties as assigned.

Skills, Knowledge, Abilities: 

• Strong organizational skills with the ability to multi-task in a fast-paced environment.  
• Ability to adapt, modify and prioritize while adhering to strict deadlines and a willingness to shift priorities to meet the needs of the organization.  
• Knowledge and understanding of medical coding and billing systems and regulatory requirements. Knowledge of legal, regulatory and policy compliance issues related to medical coding and billing procedures and documentation. 
• Excellent communication and interpersonal skills and demonstrated ability to interact with a variety of team members. 
• Self-motivated with the ability to identify opportunities for improvement and demonstrate the initiative to resolve issues in support of improvement efforts.  
• Strong analytical skills and the ability to work independently to analyze and solve problems.  
• Adept at learning proprietary software applications. 
• Collaborate with professionals, internal and external to the company, and across geographic locations.  
• Exhibit a growth mindset and team-oriented behaviors.  
• Navigate competing priorities and effectively work in a fast-paced environment.
   

Requirements

 Education: 

• Preferred: RHIA, CDI, CPC, CCS, CCS-P. 
• Bachelor’s degree or equivalent is required. 

Experience: 

• Minimum of 6 years of experience in medical coding and billing, with a focus on denial management.
• Prior experience supervising or leading a team. 
• Familiarity with various payer guidelines, including Medicare and Medicaid.

Certifications:

• Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent certification required.

Supervisory Requirements: 

• Yes 

Core Clinical Management, LLC is an equal opportunity employer and complies with ADA regulations as applicable.  Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.