Clinical Coding Audit Specialist, HIM

Jackson Health System; Miami (FL); On-site; USD 70,000 - 100,000; Full time

Job summary

Jackson Health System in Miami, FL seeks a Clinical Coding Audit Specialist, HIM to ensure DRG accuracy and regulatory compliance across the organization.

The role reviews DRG downgrades and payer denials, collaborates with CDI, coding, billing, and clinical teams, and supports appeals with detailed findings and recommendations.

Candidates typically have 5–7 years of related experience, an AHIMA or AAPC credential, and an Associate's degree; Florida RN license is a plus.

Qualifications

• 5–7 years of related experience.
• AHIMA (RHIA/RHIT/CCS/CDIP/CDEI), or AAPC (CPC/CIC/COC), or ACDIS (CCDS) certification required.
• Florida RN license is preferred.

Responsibilities

• Perform comprehensive reviews of DRG downgrades and payer denials to validate accuracy of clinical documentation and final coding.
• Validate DRG assignments per ICD 10 CM/PCS, CMS guidelines, UHDDS definitions, and policies.
• Prepare detailed findings and recommendations to support appeals when appropriate.
• Track appeals through all levels (first level, second level, external) and ensure compliance with Medicare regulations, OCE/MCE edits, LCD/NCDs.
• Provide coding expertise and documentation clarification to support appeal letters and reconsideration requests.
• Conduct internal audits of inpatient coding and DRG assignments for regulatory and payer compliance.
• Identify patterns of coding errors, documentation gaps, or compliance risks and elevate findings.
• Maintain audit logs, trends and opportunities for improvement.
• Participate in root cause analysis to reduce denials and strengthen compliance.
• Collaborate with CDI and coding teams to analyze DRG related denials and develop prevention strategies.
• Assist in developing training materials and best practice guidelines.
• Communicate audit results and compliance updates to leadership and operations.

Skills

Analytical skills

Communication skills

Stress management

Follow instructions

Independent judgment

Technology proficiency

Education

Associate's degree

Foreign physician preferred

Job description

Miami, FL Full-Time Health Information Management
Jackson Health System
Full Time

Summary

The Clinical Coding Audit Specialist, HIM ensures the accuracy, integrity, and regulatory compliance of Diagnosis Related Group (DRG) assignments across the organization. This role oversees the review, analysis, and appeal of DRG downgrades and payer denials, working closely with Clinical Documentation Improvement (CDI), coding, billing, and clinical teams to promote appropriate reimbursement and maintain compliance with regulatory requirements.

Responsibilities

• Perform comprehensive reviews of DRG downgrades and payer denials to validate the accuracy of clinical documentation and final coding.
• Validate DRG assignments in accordance with ICD 10 CM/PCS, CMS guidelines, UHDDS definitions, and organizational policies.
• Prepare detailed findings and recommendations to support appeals when appropriate.
• Track appeals through all levels (first level, second level, external review) and ensure compliance with Medicare regulations, OCE/MCE edits, and LCD/NCD requirements.
• Provide coding expertise and documentation clarification to support appeal letters and reconsideration requests.
• Conduct routine and targeted internal audits of inpatient coding and DRG assignments to ensure compliance with regulatory and payer requirements.
• Identify patterns of coding errors, documentation gaps, or compliance risks and elevate findings as needed.
• Maintain audit logs, tracking outcomes, trends, and opportunities for improvement.
• Participate in root cause analysis to reduce future denials and strengthen compliance.
• Collaborate with CDI and coding teams to analyze DRG related denials and develop prevention strategies.
• Partner with Coding and CDI teams to provide feedback, education, and clarification on DRG related issues.
• Assist in developing training materials, job aids, and best practice guidelines.
• Communicate audit results and compliance updates to leadership and operational teams.
• Analyze complex data, identify trends, and prepare reports for executive leadership.
• Maintain strong working knowledge of departmental technology solutions, recommend enhancements, and ensure optimal system performance.
• Apply independent judgment in evaluating audit findings, appeal opportunities, and compliance risks.
• Performs all other related job duties as assigned.

Experience

• Generally requires 5 to 7 years of related experience.

Education

• Associate's degree in related field is required. Foreign Physician is preferred.

Skill

• Ability to analyze, organize and prioritize work accurately while meeting multiple deadlines.
• Ability to communicate effectively in both oral and written form.
• Ability to handle difficult and stressful situations with critical thinking and professional composure.
• Ability to understand and follow instructions.
• Ability to exercise sound and independent judgment.
• Knowledge and skill in use of job appropriate technology and software applications.

Credentials

• Certification from AHIMA (e.g., RHIA, RHIT, CCS, CDIP, or CDEI), or AAPC (e.g., CPC, CIC, or COC), or ACDIS (e.g., CCDS) is required.
• Valid Florida RN license is preferred.

Jackson Health System is an equal opportunity employer and makes employment decisions without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, disability status, age, or any other status protected by law.