Coding Auditor

Senior Manager Coding IP OP

Under the general supervision of the Clinical Documentation and Coding Integrity (CDCI) Director, the Senior Manager of Coding, IP/OP is responsible for guiding the inpatient (IP) and outpatient (OP) coding and reimbursement practices for BMC South and Brighton within established regulatory and organizational guidelines. This job provides direct oversight and supervision of coding staff and related workflows, develops and maintains coding guidelines for inpatient and outpatient services, responds to billing edits and related reports to ensure accurate Diagnosis-Related Group (DRG) and Ambulatory Patient Categories / Ambulatory Patient Groups (APC/APG) assignment, and enforces the appropriate application of Official Coding Rules and Regulations, including Coding Clinic guidance.

This job provides operational leadership and supervisory oversight of coding education and staff performance, conducts systematic data quality reviews, and supports documentation integrity to ensure compliance with federal, state, and institutional regulations. Additionally, it manages coding-related Recovery Audit Contractor (RAC) reviews, external coding audits, and coding-related denial responses to secure overall coding accuracy, compliance, and reimbursement integrity across the organization.

Essential Responsibilities / Duties:

• Oversees daily inpatient (IP) and outpatient (OP) coding and reimbursement practices across BMC South and Brighton to ensure consistent application of regulatory and organizational coding standards, providing direction and oversight to coding staff as part of daily operational management.
• Develops, implements, and maintains standardized coding guidelines for inpatient and outpatient services, integrating updates from the Official Coding Guidelines and Coding Clinic.
• Reviews and analyzes complex billing edits, claim reports, and coding-related discrepancies daily to support accurate DRG and APC/APG assignments and execute corrections, including directing staff in the resolution of identified issues as needed.
• Enforces strict organizational compliance with applicable coding rules, official regulations, and internal policies by systematically monitoring coding practices and addressing deviations, including providing corrective guidance and performance feedback to coding staff when necessary.
• Conducts routine, structured data quality reviews of coded medical records to evaluate accuracy, consistency, and adherence to national documentation and coding requirements.
• Coordinates, designs, and delivers technical training and educational programs for coding staff regarding regulatory updates, advanced coding standards, and organizational policies, serving as a functional leader for coding staff development and competency building.
• Manages and coordinates institutional responses to external audits, including Recovery Audit Contractor (RAC) reviews and commercial payer audits, ensuring all documentation is submitted within required timelines, with oversight of staff participation and supporting work efforts as applicable.
• Resolves complex coding-related denial cases by reviewing determinations, validating historical coding accuracy, and preparing clinical appeals or supporting documentation, with responsibility for assigning and overseeing supporting work performed by coding staff as appropriate.
• Represents the Coding Department at interdisciplinary and clinical meetings to provide technical expertise on coding rules, documentation interpretation, and reimbursement implications, serving as a departmental lead and subject matter authority in coding operations.

Job Requirements

Required Education and Experience:

• Bachelors Degree in Health Information Management or a related field, and a minimum of five years of acute care hospital coding experience with ICD-10-CM/PCS, of which at least three years must be healthcare management experience; or an equivalent combination of education and experience.

Preferred Education and Experience:

• Five years of healthcare management experience in an academic medical setting or trauma center, with preferred experience utilizing Current Procedural Terminology (CPT-4).

Certificates, Licenses, Registrations Required:

• Certified Coding Specialist (CCS) credential

Certificates, Licenses, Registrations Preferred:

• Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) credential

Knowledge, Skills & Abilities (KSAs):

• Reimbursement Methodologies: Extensive knowledge of hospital inpatient and outpatient reimbursement methodologies, including DRG systems such as CMS DRGs, AP-DRGs, and APR-DRGs.
• Clinical Knowledge: In-depth knowledge of medical terminology, anatomy, physiology, and pathology as they relate to accurate clinical coding and reimbursement assignment.
• Coding Systems: Advanced, fluent knowledge of ICD-10-CM/PCS and CPT coding systems, including Official Coding Guidelines and regulatory coding conventions.
• Systems Proficiency: Strong understanding of health information systems, data integrity principles, and electronic health record (EHR) workflows, alongside proficiency in Microsoft Office applications.
• Analytical Skills: Ability to interpret complex clinical and coding data to isolate systemic issues, resolve discrepancies, and apply regulatory and organizational policies appropriately.
• Time Management: Strong organizational and time management skills, including the ability to prioritize competing operational demands, manage multiple deliverables, and meet tight compliance deadlines.
• Leadership & Coaching: Ability to provide structured guidance, coaching, mentoring, and informal leadership to coding staff to actively model best practices in coding accuracy and compliance.
• Regulatory Compliance: Ability to maintain strict confidentiality and ensure complete compliance with HIPAA and other privacy regulations when handling sensitive health information

Compensation Range: $97,500.00- $141,500.00

This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensures as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, BMCHS offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), discretionary annual bonuses and merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family well-being.

Note: This range is based on Boston-area data, and is subject to modification based on geographic location.

Equal Opportunity Employer/Disabled/Veterans

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