Professional Fee Coding Auditor Claims Edit Specialist (On-Site, Hybrid, Remote)

Work Location Requirement: 

• This position may be performed onsite or remotely; however, onsite work is preferred based on business needs.  Preference will be given to qualified candidates who are able to work onsite and are located within a reasonable commuting distance.

Remote Work Eligibility: 

• This position is open to candidates located within the continental United States. Due to state-specific employment requirements and workers’ compensation regulations, we are unable to support remote work arrangements in the following locations: Washington, Ohio, Wyoming, North Dakota, Puerto Rico, and the U.S. Virgin Islands.
• At Northbay Health, the Professional Fee Coding Auditor / Claims Edit Specialist is responsible for auditing professional fee coding across all service lines (Ambulatory/Hospitalist, Surgery, and Emergency Medicine), resolving pre‑billing coding edits, and reviewing post‑billing coding‑related denials.
• This role ensures coding accuracy, documentation integrity, and compliance with CPT, HCPCS, ICD‑10‑CM, and payer‑specific rules. The position supports coding quality improvement, identifies trends, provides coder feedback and physician education based on audit and edit findings, and partners with leadership to strengthen coding workflows across the organization.

Primary Job Duties

Audit Responsibilities

• Performs routine and targeted professional fee coding audits across all service lines: Ambulatory/Hospitalist (including Urgent Care and Pools), Surgery, and ED ProFee.
• Reviews documentation for completeness, accuracy, and compliance with CPT, HCPCS, ICD‑10‑CM, and payer policies.
• Identifies trends, patterns, and recurring issues affecting coding quality or compliance.
• Prepares audit summaries and provides clear, constructive feedback to coders and leadership.
• Assists in developing coder and physician education based on audit findings.

Pre‑Billing Edit Resolution

• Reviews and resolves coding‑related edits in pre‑bill work queues within the current EHR/coding platform.
• Validates CPT/HCPCS, ICD‑10‑CM, and modifier accuracy to ensure clean claims prior to billing.
• Escalates documentation deficiencies to providers using established query processes.
• Identifies edit trends and recommends workflow or rules‑based improvements.

Post‑Billing Denials Review

• Reviews coding‑related denials and determines appropriate corrective action.
• Provides coding clarification for Billing, Revenue Integrity, and Denials teams.
• Tracks denial trends and collaborates with leadership to reduce recurrence.

Coder and Physician Education

• Develops and delivers targeted coder education based on audit findings, pre bill/PB edit trends, and denial trends.
• Identifies documentation or coding patterns requiring physician level education, and coordinates with the Manager & Supervisor, Professional Coding, and/or Medical Staff leadership to schedule and deliver physician education as needed.
• Prepares education materials (tip sheets, presentations, case examples) reflecting current CPT, HCPCS, ICD 10 CM, and payer guidance.
• Measures the effectiveness of education provided by tracking improvement in subsequent audit, edit, and denial findings.

Compliance & Quality

• Ensures all work complies with CMS, AMA, OIG, payer policies, and NorthBay standards.
• Maintains strict confidentiality and HIPAA compliance.
• Supports continuous improvement of coding workflows and audit processes.

Professional Standards

• Performs other duties as assigned.