Professional Fee Coding Auditor Claims Edit Specialist (Full-Time, Day)

Professional Fee Coding Auditor

At NorthBay Health the Professional Fee Coding Auditor 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.

Qualifications

Education :

• High School diploma preferred; Associate's or Bachelor's preferred.

Certification:

• Requires one of the following credentials: CPC, CCS-P, or CPMA.
• CRC (Certified Risk Adjustment Coder) preferred in addition to one of the certifications above.

Experience:

• Minimum 5 years of professional fee coding experience across multiple specialties.
• Minimum 3 years of prior auditing and edit-resolution experience is required.
• Strong knowledge of anatomy, physiology, medical terminology, disease processes, and official coding guidelines.

Skills :

• Requires strong analytical skills, deep understanding of clinical documentation, and the ability to work independently with high accuracy in any EHR or coding/billing platform.
• Proficiency with EHRs, encoders (e.g., 3M), and Microsoft Office.

Interpersonal Skills :

• Communicates effectively with coders, providers, and cross-functional teams.
• Maintains professionalism under deadlines and shifting priorities.

Standards of Performance:

• Demonstrate performance by adhering to established policies and procedures and exhibiting the defined characteristics associated with attendance and punctuality.

Physical Effort:

• Attendance is an essential function of the job. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
• Ability to sit for extended periods.
• Ability to lift/push/pull up to 5 lbs.
• Frequent keyboarding and sustained concentration.

About Us

Interpersonal Skills and Values

Demonstrates NorthBay Health's True North Values: Nurture Care, Own It, Respect Relationships, Build Trust, and Hardwire Excellence. These values guide behavior, accountability, teamwork, and commitment to high-quality patient care.

Why NorthBay Health

NorthBay Health is an independent, nonprofit health system serving the Napa, Solano, and Yolo County regions. We are expanding access to care across our communities through two acute-care hospitals, including a Level II Trauma Center and a Level III NICU maternity unit, along with a cancer center, urgent care locations, and a growing network of primary and specialty care clinics.

We provide advanced services in cardiovascular care, neuroscience, orthopedics, surgery, and outpatient specialties. NorthBay Health is nationally recognized for quality care, including Magnet with Distinction designation for nursing and multiple U.S. News and World Report high performing recognitions.

We are committed to being the trusted healthcare partner of choice and offer an environment where employees can grow, contribute meaningfully, and support the health of our communities.

NorthBay Health Benefits Options

NorthBay Health offers a comprehensive benefits package based on established eligibility requirements. Benefits may include medical, dental, and vision insurance, life, disability, and long-term care coverage, paid time off including vacation, sick leave, holidays, and bereavement, a 403(b) retirement plan with employer match, education reimbursement for eligible roles, professional development and training programs, Employee Assistance Program, wellness programs, recognition programs, shift differentials, and market-based compensation review and increases subject to approval and organizational performance.

Compensation Structure

NorthBay Health uses a structured compensation framework. Staff-level positions use a step-based system (Steps 1–5) based on years of directly related experience, with Step 5 representing 20 or more years of experience in the role. Manager level and above positions are paid a fixed annual base salary and are eligible for a variable incentive compensation plan. Physician compensation is structured based on specialty and role requirements.

Remote Work Disclosure

NorthBay Health is primarily an onsite organization due to the nature of healthcare. Some roles may allow hybrid or remote work based on business needs.

Remote work is not supported in Washington, Ohio, Wyoming, North Dakota, Puerto Rico, the U.S. Virgin Islands, or outside of the United States.

Notice to Recruitment Agencies

NorthBay Health utilizes a managed service provider (MSP) for agency partnerships and is not currently engaging external recruiting firms outside of established agreements. We do not accept unsolicited resumes or third-party candidate submissions. Please do not contact NorthBay Health employees, leaders, physicians, or hiring managers regarding recruitment or job postings.

More Information

Visit NorthBay Health Careers for recruitment FAQs and additional information.