Coding Quality Reviewer and Educator-4

SUMMARY:

Report ing   to the   Professional Validation Manager, t he   Coding Quality Reviewer and Educator   is responsible for   performing comprehensive audits of professional coding and clinical documentation across a multispecialty ambulatory environment. This role   validates   the   accurate   assignment of ICD-10-CM, CPT, and HCPCS codes   in accordance with   CMS regulations, payer policies, organizational standards, and industry guidelines.  

This position conducts both prospective and retrospective reviews of provider and coder-selected codes, documents audit findings in a clear, objective, and non-leading manner, and   identifies   trends, risks, and opportunities for improvement.  

Serving as a subject matter expert, the Coding Quality Reviewer and Educator develops and delivers targeted education to coders, providers, and clinical departments to support compliant, defensible documentation and   optimal   revenue integrity outcomes.  

This role requires expert-level coding knowledge, strong analytical and critical thinking skills, and the ability to work independently in a fully remote environmen t. 

Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers and one another.

In addition to our values, all employees are expected to demonstrate the core Success Factors which tell us how we work together and how we get things done. The core Success Factors include:

Instill Trust and Value Differences
Patient and Community Focus and Collaborate

RESPONSIBILITIES:

• Perform prospective and retrospective audits of professional coding and medical records to   validate   accuracy and completeness of ICD-10-CM, CPT, HCPCS, and modifier assignment.  

• Evaluate clinical documentation to ensure services billed are supported, medically necessary, and compliant with CMS, federal, payer-specific, and organizational requirements.  

• Validate   both coder and provider   assigned codes; document findings, variance details, and supporting rationale in a clear,   objective , and audit-defensible format.  

• Apply non-leading, compliant review methodologies consistent with ACDIS/AHIMA guidance.  

• Identify   root causes of coding and documentation discrepancies and collaborate with leadership to develop corrective action plans.  

• Develop and   conduct   targeted education to coders, providers, and clinical departments based on audit findings, coding updates, and   identified   trends.  

• Track and trend audit results to   identify   systemic risks and opportunities for process improvement.  

• Research coding and documentation guidelines from   qualified   sources,   collects   relevant   information   and   compiles   that information into a user-friendly ma nual .  

• S tays current on coding updates,   certification   requirements , and   expertise   pertinent to the position .  

Key Skills  

• Expert   knowledge of:  

• ICD-10-CM, CPT, and HCPCS Level II coding guidelines  

• E/M coding and/or surgical/procedural coding  

• Medical terminology, anatomy, and healthcare documentation  

• Knowledge of teaching physician, split/shared visit, and incident-to billing requirements  

• Abilit y to   interpret   complex medical documentation and apply coding guidelines accurately  

• Ability to   identify   trends , analyze audit data,   and recommend process improvement  

• Ability to research and apply regulatory guidance from CMS,   MAC , and commercial payers.  

• Perform detailed audit reviews using standardized audit tools and methodologies    

• Communicate complex coding concepts clearly to providers and coders  

• Strong attention to detail and organizational skills    

• Excellent written   and verbal   communication skills  

• Proficiency   with electronic health records (EHR), Epic experience   preferred  

• Proficiency   with Microsoft Office Suite   (Word, Excel, PowerPoint)  

Compliance & Regulatory Adherence  

• Maintains expert-level compliance with CMS regulations, National Correct Coding Initiative (NCCI) edits, Medicare Administrative Contractor (MAC) guidance, payer policies, and organizational standards.  

• Participate in compliance initiatives to reduce coding-related denials and audit findings.  

• Ensures   compliance with HIPAA ,   organizational data privacy ,   and security policie s .  

• Abides by the Standards of   Ethical Coding as set forth by the American Health Information Management   Association and the American Association of Professional Coders .  

Performance Metrics  

• Meet s or exceeds 95%   coding   accuracy rate  

• Achieve s   productivity benchmarks  

• Demonstrate s   consistent performance in accuracy, timeliness, and workload management  

• Adhere s   to organizational coding guidelines, payer requirements, and documentation standards to support audit readiness and reimbursement integrity  

• Accurately   audits assigned accounts , responds to   inquires ,   and provides education     

• Delivers high-quality education that improves provider documentation and coding performance  

MINIMUM QUALIFICATIONS:

Education  

• High school diploma or equivalent required  

Certifications  

One or more of the following required:  

• CPC (Certified Professional Coder) – AAPC  

• CCS or CCS-P (Certified Coding Specialist / Physician-based) – AHIMA  

If applicable, s pecialty certification in assigned area   required   within one (1) year of hire .  

Experience  

• Minimum of five (5) years of professional coding experience, preferably in a large academic or   multispecialty   setting.  

• Prior coding audit experience   strongly   preferred.  

• Prior   experience performing provider   and coder   education   strongly preferred.   

Work Environment  

Fully Remote:   Must maintain a secure, private workspace to protect PHI .   Required to use organization-approved secure systems (VPN, multi-factor authentication) .   Maintains active communication via email, messaging platforms, and   attends   virtual meeting s , as scheduled .  

Working conditions:   Requires   pro long ed computer use   to review medical records .    Ability to meet deadlines while achieving productivity and accuracy standards.  

Independent action:   Performs independently with minimal supervision and serves as a subject matter expert. Exercises advanced judgment in interpreting coding guidelines and resolving complex issues   within the department’s policies and practices.   Refers   specific complex problems to the supervisor when clarification of the departmental policies and procedures are   required .    

Supervisory responsibility:   None  

Disclaimer  

This job description is intended to describe the general nature and level of work performed. Duties and responsibilities may be adjusted based on organizational needs and regulatory requirements.  

Pay Range:

$67,724.80-$111,716.80

EEO Statement:

Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment.

Location:

Corporate Headquarters - 15 LaSalle Square Providence, Rhode Island 02903

Work Type:

M-F 8:00am-5:00pm

Work Shift:

Day

Daily Hours: 

8 hours

Driving Required:

No