Coding Quality Auditor (RN)

JOB SUMMARY

The RN, Coding Quality Auditor is a highly specialized, enterprise-critical role responsible for safeguarding the accuracy, integrity, and completeness of clinical documentation and coded data across inpatient and outpatient services.

This position plays a pivotal role in revenue integrity, regulatory compliance, and risk adjustment performance, with a strong focus on Hierarchical Condition Category (HCC) capture and Risk Adjustment Factor (RAF) optimization. Through comprehensive chart audits, the incumbent ensures that all diagnoses and procedures are captured with the highest level of specificity, fully supported by clinical documentation, and aligned with CMS and payer guidelines.

Leveraging advanced expertise in Meditech Expanse and leading coding technologies, this role translates clinical documentation into compliant, optimized coding outcomes that support both fee-for-service and value-based reimbursement models.

This role serves as a critical link between clinical operations, coding, and financial performance, driving accuracy in clinical representation while maximizing compliant reimbursement.

PRINCIPLE FUNCTIONS include the following, other duties may be assigned:

Coding Quality & Risk Adjustment Auditing

• Conduct comprehensive audits of clinical documentation and coded data to ensure accurate assignment of:
• ICD-10-CM/PCS
• CPT and HCPCS
• HCC classifications
• Validate risk adjustment accuracy, ensuring appropriate capture, abstraction, and submission of HCCs
• Verify diagnoses meet MEAT criteria (Monitor, Evaluate, Assess, Treat)
• Ensure coding reflects the highest level of specificity and clinical accuracy
• Identify and correct under-coding, over-coding, and documentation gaps impacting reimbursement

Systems & Technology Expertise

• Demonstrates advanced proficiency in Meditech Expanse EHR, including:
• Clinical documentation navigation
• Abstracting workflows
• Coding review processes
• Utilize best-in-class coding and auditing technologies, including:
• 3M Encoder / 360 Encompass
• Optum CAC (Computer-Assisted Coding)
• TruCode Encoder
• EPIC (in hybrid environments, as applicable)
• Leverage system reporting tools to:
• Identify coding and documentation trends
• Monitor HCC capture and RAF performance
• Analyze denial patterns and revenue leakage
• Partner with IT and system analysts to optimize:
• Coding workflows
• System edits and automation
• Charge capture processes

Revenue Capture & Integrity

• Ensure complete and accurate revenue capture for both facility and professional services, including RVU optimization
• Identify missed revenue opportunities and gaps in documentation or coding
• Drive measurable improvements in RAF accuracy and overall financial performance through targeted audit insights and interventions
• Collaborate with RCM teams to reduce denials and prevent revenue leakage
• Support reconciliation between clinical documentation, coding outputs, and billed data to ensure end-to-end revenue integrity

Compliance & Regulatory Oversight

• Ensure adherence to CMS regulations, risk adjustment guidelines, and payer-specific requirements
• Perform pre-bill and post-bill audits across care settings
• Identify compliance risks and develop corrective action plans
• Maintain audit readiness for external reviews (e.g., RADV, payer audits)

Provider Collaboration & Clinical Validation

• Partner directly with providers to:
• Clarify diagnoses
• Validate clinical documentation
• Close documentation gaps
• Serve as a trusted advisor on documentation and risk adjustment requirements
• Deliver clear, respectful, and actionable feedback to improve documentation quality
• Align provider documentation with compliant coding and reporting standards

Education & Continuous Improvement

• Develop and deliver targeted education for:
• Providers
• Coders
• Revenue cycle staff
• Translate audit findings into actionable training and performance improvement initiatives
• Ensure stakeholders remain current on:
• Coding guideline updates
• Risk adjustment model changes
• Payer policy updates

Audit Analytics & Performance Monitoring

• Track and analyze key performance indicators, including:
• Coding accuracy rates
• HCC capture rates
• RAF score impact
• Coding- and documentation-related denial trends
• Identify root causes of performance gaps and implement sustainable improvements
• Provide data-driven insights and reporting to RCM leadership

JOB KNOWLEDGE & QUALIFICATIONS

Education

• Graduate of an accredited school of nursing.
• BSN preferred.

Training and Experience

• 5+ years of progressive coding experience across inpatient and outpatient settings
• Advanced expertise in risk adjustment (HCC coding and RAF methodologies)
• Demonstrated experience in coding audits, compliance, and revenue integrity
• Proven success improving coding accuracy and reimbursement outcomes
• Experience collaborating with providers and clinical teams

Core Competencies

• Advanced knowledge of risk adjustment models and reimbursement methodologies
• Deep understanding of Meditech Expanse and EHR-driven workflows impacting coding and revenue
• Ability to integrate clinical documentation, coding standards, and system functionality
• Strong analytical, problem-solving, and data interpretation skills
• Exceptional communication skills with ability to translate complex concepts clearly
• High attention to detail and commitment to compliance and integrity
• Collaborative, solutions-oriented mindset

Preferred Attributes

• Experience supporting Medicare Advantage and other major payer programs, including value-based care models, with strong understanding of risk-adjusted reimbursement, HCC coding, and RAF optimization
• Background in denial prevention and appeals related to coding/documentation
• Familiarity with Clinical Documentation Integrity (CDI) programs
• Ability to influence provider engagement through education and data

Certificates, Licenses, Registrations

• Active WA State RN License or Active Multistate License (MSL)
• MSL Requirements:
• Approved 6-Hour Suicide Prevention Training Course Completion
• Screenshot of submitted demographic data using the Washington State Multistate Nurse Demographic Data Survey.
• Required certification (one or more):
• CCS, CPC, CRC, RHIT, or RHIA
• CRC strongly preferred (risk adjustment focus )

Health & Well-Being You Can Count On

We offer a thoughtful, comprehensive benefits package designed to support you and your family at every stage of life:

• Medical Coverage – HDHP w/HSA / PPO
• Prescription Drug Coverage
• Dental Options – PPO / Managed-Care Plan
• Vision Benefits – VSP
• Life & AD&D Insurance – Employer paid coverage
• Long-Term Disability Coverage – Employer paid income Protection
• Health Savings Account (HSA) – If enrolled in HDHP
• Healthcare Flexible Spending Account (FSA) – Dependent & Healthcare
• Employee & Provider Assistance Programs – Free, confidential support
• Voluntary Life & AD&D Insurance – Additional employee paid buy up option
• Voluntary Long-Term Disability Coverage – Additional employee paid buy up option