Coding Compliance Specialist

Job Title: Billing and Coding Compliance Specialist

Department: Revenue Cycle / Compliance

Reports To: Director of Revenue Cycle

Location: Bronx

Job Summary:

The Billing and Coding Compliance Specialist is responsible for ensuring that all billing and coding activities across the organization are accurate, compliant with applicable laws and regulations, and aligned with internal policies. Responsible for ensuring timely responses to Insurances regarding audit requests. This role works closely with billing staff, coders, healthcare providers, and compliance officers to identify risk, provide education, and ensure integrity in revenue cycle operations.

Key Responsibilities:

·       Respond in a timely manner to Insurance audit requests.

·       Review clinical documentation and coding to ensure appropriate CPT, ICD-10, and HCPCS codes are assigned, and documentation meets coding billing submitted.

·       Identify and report compliance risks and recommend corrective actions to mitigate risk.

·       Collaborate with customer service and billing staff to provide guidance and feedback on patient disputes.

·       Formally escalate identified compliance risks, adverse audit findings, potential regulatory exposure, and patterns of non-compliance to Medical Directors and Executive Leadership in accordance with the organization’s compliance and governance framework.

·       Oversee and ensure full-cycle audit compliance management, including receipt, risk assessment, investigation, corrective action planning, payer response submission, monitoring, and documented closure of all external audits to ensure regulatory adherence and defensible outcomes.

·       Assist in the development, implementation, and enforcement of policies and procedures related to billing and coding compliance.

·       Investigate and resolve coding or billing discrepancies.

·       Prepare and maintain documentation of audit results, findings, and improvement plans.

·       Support external audits and respond to requests for documentation or clarification.

·       Stay current on updates to coding regulations, payer policies, and compliance requirements.

·       Participate in compliance committees and contribute to continuous improvement initiatives.

·       Ethico patient grievances related to billing and coding.

KPIs

·       Documentation completeness: 100% of audits maintained with complete audit trails, including findings, responses, remediation, and closure sign-off.

·       Repeat finding reduction: ≥ 25% year-over-year reduction in repeat audit findings related to billing and coding non-compliance.

·       Corrective action completion rate: 100% of approved corrective action plans are implemented and validated within defined timelines.

·       Audit closure turnaround time: ≥ 90% of audits fully resolved and formally closed within payer or regulatory deadlines.

·       Audit response timeliness: ≥ 95% of payer and regulatory audit requests acknowledged within 5 business days.

Qualifications:

Education & Certification:

• High School Diploma or equivalent required; associate or bachelor's degree preferred.
• Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent credential required.
• Certified in Healthcare Compliance (CHC) a plus.

Experience:

• Minimum of 3 years of experience in medical billing, coding, or compliance auditing.
• Strong knowledge of Medicare, Medicaid, and commercial payer rules.
• Familiarity with EHR and billing systems (e.g.,eClinicalWorks).

Skills & Competencies:

• Strong attention to detail and analytical skills.
• Excellent communication and interpersonal skills.
• Ability to handle confidential information with integrity.
• Proficiency in Microsoft Office Suite, especially Excel and Word.

Working Conditions:

• Primarily office-based with occasional travel for training or audits.
• Standard business hours with flexibility as needed to meet deadlines or address urgent compliance issue