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Job Summary The DRC Coding Auditor within the Denial Resource Center partners closely with a multi-disciplinary team that include Certified Coders, Clinical Validation Registered Nurses, Revenue Cycle teams, and Payer Liaisons to resolve complex coding-related denials for both Hospital Billing (HB) and Professional Billing (PB) claims. This role is responsible for reviewing, auditing, and appealing moderate to high-complexity coding denials, including MUE denials, DRG downgrades, clinical validation-related coding disputes, modifier denials, and payer coding validation determinations.
The DRC Coding Auditor applies advanced knowledge of inpatient and outpatient coding, reimbursement methodologies, CMS regulations, payer policies, and billing requirements to evaluate denied claims and develop successful appeal strategies. This role works closely with Clinical Validation RNs to ensure documentation, coding, and clinical evidence support the billed services and reported diagnoses. In addition to denial resolution, the DRC Coding Auditor identifies denial trends, performs root cause analysis, and collaborates with operational and clinical stakeholders to improve coding accuracy, reduce preventable denials, and enhance revenue cycle performance.
- of the Role Review and audit coding-related denials to determine appropriate resolution and appeal strategies based on coding guidelines, payer rationale, regulatory requirements, and medical record documentation. Investigate and appeal complex Hospital Billing (HB) and Professional Billing (PB) denials, including MUE denials, DRG downgrades, coding validation denials, modifier denials, and other coding-related reimbursement reductions. Apply advanced knowledge of ICD-10
- CM, ICD-10
- PCS, CPT, HCPCS, DRG assignment methodologies, NCCI edits, MUE guidelines, and payer-specific coding requirements when evaluating denied claims. Prepare and submit clear, concise, and compliant appeal documentation supported by coding guidelines, regulatory references, and medical record documentation. Independently research, analyze, and validate coding and reimbursement positions; effectively communicate and support recommendations using coding guidelines, regulatory requirements, payer policies, and clinical documentation when differing viewpoints exist. Perform root cause analysis to identify recurring denial trends, coding opportunities, documentation deficiencies, payer processing errors, and reimbursement risks. Communicate denial findings, appeal outcomes, and trend analysis to DRC leadership and operational stakeholders to support denial prevention initiatives. Maintain accurate documentation and account activity within designated systems to ensure audit readiness and compliance with organizational standards. Monitor assigned inventory, appeal deadlines, and payer response timeframes to ensure timely resolution of denials and recovery opportunities. Support education and process improvement efforts by providing feedback and recommendations related to coding compliance, documentation integrity, billing practices, and denial prevention. Key Success Factors High school diploma or GED required; Associate's or Bachelor's degree in Health Information Management, Healthcare Administration, Nursing, or related field preferred. Certified Professional Coder (CPC), Certified Coding Specialist (CCS), CCS-P, RHIT, RHIA, or equivalent coding certification required or preferred. Six (6) or more years of experience in coding, coding audits, denial management, appeals, revenue cycle operations, or health information management. Advanced knowledge of inpatient and outpatient coding principles, including ICD-10
- CM, ICD-10
- PCS, CPT, HCPCS, DRG assignment, NCCI edits, and MUE guidelines. Strong understanding of CMS regulations, Medicare and Medicaid billing requirements, reimbursement methodologies, and commercial payer coding policies. Experience reviewing and appealing coding denials for both Hospital Billing (HB) and Professional Billing (PB) claims. Demonstrated ability to perform root cause analysis, identify denial trends, and recommend process improvements to reduce future denials. Ability to collaborate effectively with Clinical Validation RNs, coders, and revenue cycle teams to resolve complex denial issues. Proficiency with Epic, encoder software, payer portals, and Microsoft Office applications, including Excel and Word. Excellent analytical, written, and verbal communication skills with the ability to develop persuasive, evidence-based appeal arguments and effectively manage competing priorities in a high-volume environment. Belonging Statement We believe that all people should feel welcomed, valued and supported. QUALIFICATIONS EDUCATION - H.S. Diploma/GED Equivalent EXPERIENCE - 6 Years of Experience CERTIFICATION/LICENSE/REGISTRATION - Must have one of the following registrations/certifications. Two of the six years of experience should be as a coding auditor. Registered Health Information Administrator (RHIA) Registered Health Information Technologist (RHIT) Certified Coding Specialist (CCS) Certified Coding Specialist Physician-based (CCS-P) Certified Professional Coder (CPC) Certified Outpatient Coder (COC) Certified Inpatient Coder (CIC) Certified Interventional Radiology Cardiovascular Coder (CIRCC)
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