Senior Executive - Coding Auditor

Skills Required

• Strong analytical and critical-thinking skills

• Excellent medical record review and interpretation skills

• Effective written and verbal communication

• Ability to work independently and manage multiple priorities

• Knowledge of denial management and appeals processes

• Strong problem-solving and research capabilities

  Performance Metrics

• Quality Accuracy ≥ 98%

• Achievement of Productivity Targets

• SLA/TAT Adherence

• Compliance with Process and Documentation Standards

• Minimal Audit Defects and Rework

Responsibilities

• Review and resolve Code Edit, Provider Payment Integrity (PPI), PCI, and Appeals work queues.
• Analyze medical records, provider documentation, claim history, and coding guidelines.
• Validate CPT, HCPCS, ICD-10-CM, modifiers, and reimbursement methodologies.
• Apply CMS, NCCI, Medicare, Medicaid, and commercial payer editing guidelines.
• Research coding disputes and provide supporting rationale for determinations.
• Maintain productivity, quality, and turnaround time targets.
• Escalate complex coding scenarios and policy interpretation issues appropriately.
• Update productivity, clarification, and audit logs daily.
• Participate in internal and external quality audits.
• Identify trends and recommend process improvements.
• Ensure compliance with HIPAA, OIG, and organizational policies.
• Respond promptly to client and leadership communications.

Qualifications

Qualifications & Experience

• Life Science / Paramedical / Healthcare-related degree

• Active CPC, CCS certification

• Strong knowledge of CPT, HCPCS, ICD-10-CM, NCCI edits, CMS guidelines, and payer policies

• Proficiency in MS Office and healthcare applications

• Willing to work in Eastern (US) shift when required

  Experience

• Minimum 2+ years of medical coding experience

• Experience in Surgery, E&M, or Denial Management is mandatory.

• Experience in code edit review, appeals, grievances, provider disputes, or payment integrity programs is an advantage

Working Hours

• Full-time (40 hours per week)
• Shift timing based on business requirements
• Weekends Off (subject to project need)