Nurse Coder Auditor HBA

The Nurse Coding Auditor is responsible for reviewing medical records, clinical documentation, itemized bills, and facility claims to validate accurate revenue codes, CPT codes, HCPCS codes, and related billing practices. This role applies coding principles, industry standards, coding and CMS guidelines, and company/client policies to support hospital bill audits (HBA) and itemized bill reviews (IBR).

Role and Responsibilities

• Validate the accuracy of CPT, HCPCS, revenue codes, and billed line-item charges on outpatient and inpatient facility claims.
• Review medical records and supporting documentation to confirm that billed services, supplies, and items are appropriately documented and billed accurately.
• Apply CMS guidance, coding guidelines, MUE/NCCI edits, industry standards, and policies during claim review.
• Perform itemized bill reviews, including validation of revenue code line items and supporting documentation.
• Conduct hospital bill audits to evaluate billed line charges and identify potential coding, billing, or documentation issues.
• Assess medical necessity as part of claim review activities.
• Prepare appeal responses using applicable coding guidance, industry standards, and company/client policies.
• Assist with new concept development and claim selection criteria.
• Maintain required certifications and continuing education requirements.

Qualifications

• Active coding certification in good standing, such as CCS, CPC, COC, RHIT, or RHIA.
• Strong knowledge of CPT, HCPCS, ICD-10, revenue codes, CMS and coding guidelines.
• Knowledge of inpatient coding and billing guidelines, hospital bill audits, itemized bill reviews, and line-level claim review.
• Ability to review and interpret complex medical documentation.
• Experience with coding validation, auditing, or claims review.
• Strong verbal and written communication skills.
• Ability to prioritize tasks effectively and manage multiple review activities.
• Proficiency with Microsoft Office, especially Excel.

Preferred Skills

• Registered Nurse (RN) license
• Hospital bill audit/ itemized bill review experience
• Appeals experience.
• Client communication experience.
• Experience supporting concept development or audit criteria development.
• Experience with machine learning or artificial intelligence tools in a healthcare, coding, or auditing environment.
• Experience with Encoder, Codify, TruCode/TruBridge, 3M, WebStrat, or similar coding and audit platforms.

Mental and Physical Demands

• This position will be exposed mainly to an indoor office environment and will be expected to work in or around computers and printers.
• The nature of the work is sedentary, and the employee will be sitting most of the time.
• Essential physical functions of the job include typing and the repetitive motion to utilize computer software and hardware continuously throughout the day.
• Essential mental functions of this position include concentrating on analytical tasks, reading information, and verbal/written communication to others continuously throughout the day.

Related duties as assigned

• This job description documents the general nature and level of work but is not intended to be a comprehensive list of activities, duties, or responsibilities required for this position. Consequently, employees may be asked to perform other duties as required.
• Employees may also be asked to complete certain compliance requirements set forth by our Business Partners in the performance of their jobs including but not limited to requests for background and drug screenings and disclosures of personal health information or personally identifiable information. Exemptions as provided under the ADA and TITLE VII of the Civil Rights Act will be observed and followed.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the functions outlined above.