Coding Auditor / Educator

Job Description

ABOUT THE ROLE\n

The Coding Auditor / Educator is responsible for conducting coding and documentation audits to evaluate compliance with federal and state regulations, payer requirements, and organizational policies. As a member of the Legal & Compliance Department, this individual contributor role supports the effectiveness of the organization’s compliance program by identifying coding risks, monitoring documentation accuracy, validating reimbursement integrity, and recommending corrective actions.

This role ensures accurate risk adjustment coding, HCC capture, and E/M documentation in a full-risk, value-based care environment. The position supports compliance with CMS-HCC risk adjustment guidelines, OIG audit expectations, and RADV preparedness. Working closely with providers, clinical leadership, revenue cycle, population health, and compliance teams, the Coding Auditor / Educator performs retrospective and prospective audits, analyzes coding trends, supports regulatory readiness, and delivers targeted education to providers and coding staff across WellMed Optum Florida’s clinic network of approximately 1,600 employees and 94 clinic locations in the Tampa, Orlando, and Southern Florida regions.

•    Perform prospective and retrospective coding audits of provider documentation, focusing on ICD-10-CM accuracy, HCC code capture, and E/M level selection.

•    Monitor for potential upcoding, unbundling, and unsupported diagnoses.

•    Audit encounters for documentation sufficiency supporting reported diagnoses, with emphasis on risk adjustment data validation (RADV) standards.

•    Conduct focused audits in response to compliance concerns, OIG work plan priorities, or payor-initiated reviews.

•    Support annual risk adjustment coding accuracy assessments and chart review programs.

•    Prepare detailed audit reports, findings summaries, and corrective action recommendations for providers, operational leaders, and compliance leadership.

•    Identify coding trends, error patterns, and areas of risk across providers and clinics.

•    Monitor audit outcomes and track corrective action plans to ensure timely resolution of identified deficiencies.

•    Analyze coding and audit results to identify recurring trends, educational opportunities, and areas of elevated compliance risk.

•    Maintain audit documentation and supporting records in accordance with compliance program requirements and applicable retention policies.

•    Provide coding audit metrics and trend analyses to support compliance reporting, governance activities, and organizational risk monitoring.

•    Collaborate with other internal audit teams as appropriate.

•    Develop and deliver provider and staff education on accurate coding and documentation practices, including HCC coding, E/M guidelines, and CMS-specific requirements.

•    Create training materials, tip sheets, and reference guides tailored to value-based care documentation needs.

•    Provide one-on-one provider feedback sessions based on audit findings.

•    Conduct new provider orientation on coding and documentation expectations.

•    Stay current on CMS-HCC model updates, ICD-10-CM changes, E/M guideline revisions, and OIG enforcement trends.

•    Collaborate with clinical leadership to integrate coding education into quality improvement initiatives.

•    CPC, CCS, CRC, or equivalent coding certification.

•    Minimum 3+ years of medical coding experience with at least 2 years in a coding audit or educator role.

•    Demonstrated expertise in risk adjustment / HCC coding in a Medicare Advantage or value-based care setting.

•    Strong knowledge of ICD-10-CM, CPT, CMS-HCC risk adjustment methodology, and E/M documentation guidelines.

•    Experience with RADV audit preparation and chart review processes.

•    Familiarity with CMS regulations, OIG compliance guidance, and FWA requirements.

•    Excellent presentation and interpersonal skills with the ability to educate providers at all levels.

•    Proficiency in EMR systems and audit tools.

•    Ability to travel to clinic sites across Florida as needed.

•    CPMA (Certified Professional Medical Auditor) certification strongly preferred.

•    Experience with coding analytics platforms.

WellMed Optum Florida is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, genetic information, or any other characteristic protected by applicable federal, state, or local law.

WellMed Optum Florida is committed to providing reasonable accommodations to qualified individuals with disabilities in accordance with the Americans with Disabilities Act (ADA) and applicable state laws. Applicants who require accommodation should contact Human Resources.