Medical Coder - (Audit Specialist)

Position Summary    

The Medical Coder/Audit Specialist position is an exempt salaried position that ensures that AAAI’s coding, documentation, and billing practices are accurate, compliant, and aligned with payer regulations. This role reduces risk exposure, strengthens revenue capture, manages payer portals, and supports providers through education and proactive auditing. This position supports timely submission of insurance claims to a wide variety of payers and functions as an intermediary between healthcare providers, clients, patients and health insurance companies. 

• Must be certified from an accredited organization such as AAPC (CPC) (CCS) is required in coding and / or billing.

Reports To: Medical Practice Administrator 

Principal Duties and Responsibilities 

1. Revenue Protection & Growth

• Accurate Coding = Correct Reimbursement: Ensures all CPT/ICD-10 codes and HCPCS are properly supported, reducing underpayments.
• Audit-Driven Optimization: Identifies missed billable opportunities (e.g., modifiers, add-on codes).
• Payer Portal Management: Monitors real-time claim status, eligibility verification, and payer communications to reduce revenue leakage.
• ROI Impact: Every 1% improvement in coding accuracy equates to significant annual revenue recovery across 7 AAAI clinics.

2. Denial Prevention

• Front-End Risk Mitigation: Reduces avoidable denials through pre-claim audits and provider training.
• Analyze Data: analyze patient records and documentation to extract relevant information for coding.
• Trend Analysis: Tracks payer denial patterns and provides feedback loops to billing and operations.
• Portal-Driven Resolution: Uses payer portals to identify denial root causes and expedite corrections/resubmissions.
• Result: Higher first-pass claim acceptance → faster cash flow → lower AR days.

3. Compliance & Risk Reduction

• Regulatory Alignment: Keeps AAAI compliant with CMS and payer policies, including HIPAA, to maintain patient confidentiality and data security.
• Audit Preparedness: Reduces exposure to recoupments during external audits 
• Documentation Support: Ensures providers’ charts withstand legal and payer scrutiny.
• Portal Accuracy: Verifies payer policies and coding requirements directly within payer portals to avoid compliance risks.
• Stay Updated: keep abreast of changes in coding standards and regulations to ensure compliance and accuracy in coding practices.

4. Provider & Staff Support

• Provides coding education to physicians, PAs, and clinical staff.
• Develop quick-reference tools to improve documentation accuracy.
• Acts as a resource for operational leaders on payer rules, portal updates, and coding changes.
• Other duties as assigned. 

Required Knowledge, Skill and Abilities

    1.    Must have experience with third party billing of physician services.

2.    Strong organizational skills with ability to manage multiple workstreams.

3.    Excellent communication and interpersonal skills.

4.    Excellent written and verbal communication skills.

5.    Knowledge of regulatory requirements and healthcare laws.

6.    Ability to analyze data and make informed decisions.

7.    Strong organizational and time management skills.

8.    Ability to work well under pressure and in a fast-paced environment.

9.    Ability to engage confidently with physicians, staff, and community partners.

10.  Proficiency in Microsoft Office Suite and EMR/credentialing systems.

11.  Ability to understand and interpret policies and regulations.

12.  Ability to read and interpret medical charts.

13.  Ability to examine documents for accuracy and completeness.

14.  Ability to understand and interpret EOB’s/ERA’s

15.  Strong understanding of medical terminology.

Education

• Must have a high school diploma or equivalency.
• Must be certified from an accredited organization such as AAPC (CPC) (CCS) is required in coding and / or billing.
• An associate or bachelor’s degree in health information management is preferred.

 Experience

• Minimum of four years of directly related experience. 
• Minimum of two years’ billing and/or collections experience in a health care organization. Two or more years preferred.

Other Requirements

Success Metrics

• ≥ 95% coding accuracy rate.
• Year-over-year reduction in avoidable denials.
• Measurable increase in reimbursement capture (CPT utilization, correct modifier application, portal-driven optimization).
• Full compliance during external audits. 

Working Conditions

OSHA Category 3: Involves no regular exposure to blood, body fluids, or tissues, and tasks that involve exposure to blood, body fluids, or tissues are not a condition of employment.  Position is in a well-lighted office environment.  Occasional evening and weekend work.  Requires sitting and standing associated with a normal office environment. Manual dexterity using calculator.  Standard office equipment will be operated including computers, fax machines, copiers, printers, telephones, calculators, etc.