Coding Compliance Specialist 1/ Auditor

About the Role 

The Coding Compliance Specialist supports Compliance by conducting audits, investigations, and regulatory response activities related to billing, coding, documentation, privacy, and quality-of-care concerns. 

This role is responsible for responding to incidents reported through the compliance hotline, performing coding and documentation audits, supporting privacy investigations, and coordinating responses to government payer inquiries. The position plays a key role in identifying compliance risks, ensuring adherence to regulatory requirements, and supporting corrective action initiatives across the organization. 

Essential Duties and Responsibilities 

Compliance Investigations & Hotline Response: 

• Review and respond to compliance hotline reports related to billing, coding, documentation, quality of care, and privacy concerns 

• Conduct investigations and document findings, including root cause analysis and resolution 

• Collaborate with Compliance, Revenue Cycle Management, Hospital Partners, and reporters. 

• Escalate high-risk or regulatory issues as appropriate 

Audit & Monitoring: 

• Perform retrospective and focused audits of medical records to evaluate: 

• Coding accuracy (CPT, ICD-10-CM, HCPCS) 

• Documentation completeness and medical necessity 

• Conduct audits in response to identified risks, hotline complaints, and payer requests 

• Identify trends and potential areas of non-compliance 

• Prepare clear, concise audit reports with recommendations 

Corrective Action & Education: 

• Develop and support the implementation of corrective action plans (CAPs) 

• Partner with operational and clinical leadership to ensure remediation 

• Provide education and guidance to providers and staff on coding, documentation, and compliance requirements 

• Conduct follow-up reviews to assess the effectiveness of corrective actions 

Privacy & Compliance Support: 

• Support privacy-related investigations, including potential HIPAA concerns 

• Assist in documenting findings and mitigation activities 

• Maintain confidentiality of all protected and sensitive information 

  

Government & Payer Response: 

• Coordinate and prepare documentation submissions (i.e., Attorney General, CMS) 

• Assist with analysis of payer findings and implementation of required actions 

  

Data Analysis & Reporting: 

• Analyze large data sets to identify trends, anomalies, and risk areas 

• Maintain audit and investigation tracking logs 

• Support compliance reporting and program metrics 

Values 

• Collaboration: Demonstrates the ability to work well with others to accomplish a goal and get the work done; takes opinions of others into consideration; includes others in the decision-making process  


• Drive: Motivated to succeed and get things done at a high level of achievement 

• Intellectual Curiosity: Demonstrates a genuine interest in learning new things and wants to know the reason “why” behind the way things are done 

• Commitment: Demonstrates dedication to the job, project, organization, customer/clients and co-workers 

• Strategic Thinking: Demonstrates the ability to look at the big picture and proactively develop a plan of action 

• Teamwork: Proactively seek to work with others to accomplish a common goal. Willingness to share challenges and successes with others 

• Trustworthiness: Demonstrates a high degree of integrity; keeps confidences; does what they say they will do 

  

Knowledge, Skills, and Abilities 

• Strong knowledge of CPT, ICD-10-CM, and HCPCS coding guidelines 

• Understanding of federal and state regulations related to billing, coding, and privacy 

• Ability to conduct detailed audits and investigations 

• Strong analytical skills with the ability to process large data sets 

• Excellent written and verbal communication skills 

• High attention to detail and organizational skills 

• Ability to manage multiple priorities in a fast-paced environment 

• Proficiency in Microsoft Word and Microsoft Office Suite 

• Ability to work independently and collaboratively across departments 

• May require interaction with clinical staff, leadership, and external stakeholders 

• Maintains strict confidentiality in all aspects of work 

  

Education & Experience 

• Bachelor’s degree in healthcare, business, or related field preferred, or equivalent experience 

• Minimum of 3–5 years of experience in coding, auditing, compliance, or related healthcare field 

• Required: Active coding certification from AAPC (e.g., CPC or equivalent) 

• Preferred: Certification in Healthcare Compliance (CHC) or other HCCA-related certification