Coding Quality Reviewer and Educator-3

Rhode Island Hospital; United States; Remote; USD 70,000 - 100,000; Full time

Job summary

Brown University Health is seeking a Coding Quality Reviewer and Educator to audit professional coding and clinical documentation across a multispecialty ambulatory setting. The role ensures accurate ICD-10-CM, CPT, and HCPCS coding per CMS regulations and payer policies.

The candidate will educate coders and clinicians to support compliant documentation and revenue integrity. This position is fully remote within the United States.

Qualifications

• Expertise in ICD-10-CM, CPT, HCPCS coding and modifiers.
• Ability to review clinical documentation for accuracy and compliance.
• Strong analytical, audit, and non-leading communication skills.
• Proficiency with EHRs and reporting tools.
• Knowledge of CMS, MAC guidance, and payer policies.

Responsibilities

• Perform prospective and retrospective audits of professional coding and records for accuracy.
• Evaluate documentation for medical necessity and compliance with CMS and payer policies.
• Document audit findings in a clear, objective, defensible format.
• Identify root causes and collaborate on corrective action plans.
• Develop and deliver targeted education to coders and clinicians.
• Track trends to identify systemic risks and improvement opportunities.
• Stay updated on coding guidelines and regulatory changes.

Skills

ICD-10-CM

CPT

HCPCS Level II

E/M coding

Surgical/procedural coding

Medical terminology

Audit data analysis

CMS/MAC guidance

EHR proficiency

Education

High school diploma

Tools

Epic

Job description

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