Clinical Coding Audit Specialist, HIM

Miami, FL • Full-Time • Health Information Management

About the role

The Clinical Coding Audit Specialist, HIM ensures the accuracy, integrity, and regulatory compliance of Diagnosis Related Group (DRG) assignments across the organization. This role oversees the review, analysis, and appeal of DRG downgrades and payer denials, working closely with Clinical Documentation Improvement (CDI), coding, billing, and clinical teams to promote appropriate reimbursement and maintain compliance with regulatory requirements.

Responsibilities

• Perform comprehensive reviews of DRG downgrades and payer denials to validate the accuracy of clinical documentation and final coding.
• Validate DRG assignments in accordance with ICD 10 CM/PCS, CMS guidelines, UHDDS definitions, and organizational policies.
• Prepare detailed findings and recommendations to support appeals when appropriate.
• Track appeals through all levels (first level, second level, external review) and ensure compliance with Medicare regulations, OCE/MCE edits, and LCD/NCD requirements.
• Provide coding expertise and documentation clarification to support appeal letters and reconsideration requests.
• Conduct routine and targeted internal audits of inpatient coding and DRG assignments to ensure compliance with regulatory and payer requirements.
• Identify patterns of coding errors, documentation gaps, or compliance risks and escalate findings as needed.
• Maintain audit logs, tracking outcomes, trends, and opportunities for improvement.
• Participate in root cause analysis to reduce future denials and strengthen compliance.
• Collaborate with CDI and coding teams to analyze DRG-related denials and develop prevention strategies.
• Partner with Coding and CDI teams to provide feedback, education, and clarification on DRG-related issues.
• Assist in developing training materials, job aids, and best practice guidelines.
• Communicate audit results and compliance updates to leadership and operational teams.
• Analyze complex data, identify trends, and prepare reports for executive leadership.
• Maintain strong working knowledge of departmental technology solutions, recommend enhancements, and ensure optimal system performance.
• Apply independent judgment in evaluating audit findings, appeal opportunities, and compliance risks.
• Perform all other related job duties as assigned.

Requirements

• Generally requires 5 to 7 years of related experience.
• Associate's degree in a related field is required.
• Foreign Physician is preferred.

Skills

• Ability to analyze, organize, and prioritize work accurately while meeting multiple deadlines.
• Ability to communicate effectively in both oral and written form.
• Ability to handle difficult and stressful situations with critical thinking and professional composure.
• Ability to understand and follow instructions.
• Ability to exercise sound and independent judgment.
• Knowledge and skill in the use of job-appropriate technology and software applications.

Qualifications

• Certification from AHIMA (e.g., RHIA, RHIT, CCS, CDIP, or CDEI), or AAPC (e.g., CPC, CIC, or COC), or ACDIS (e.g., CCDS) is required.
• Valid Florida RN license is preferred.