Medical Coding Auditor Specialist

Are you ready to make a difference in the healthcare industry? Join PacificSource and play a vital role in helping our members access quality, affordable care! As an equal opportunity employer, PacificSource is committed to diversity and inclusivity in our hiring practices. All qualified candidates will be considered without regard to any protected status. The Medical Coding Auditor Specialist will engage with complex claims by utilizing advanced adjudication skills, and providing clinical interpretation to resolve grievances and appeals. You'll work collaboratively to refine our claims research policies with an emphasis on process improvement. Your expertise will be crucial in identifying potential fraud and managing erroneous payment recoveries. Key Responsibilities: Engage in the provider and member appeals process, addressing intricate claim issues with advanced adjudication expertise. Offer guidance on claims requiring in-depth research, conducting clinical evaluations, and reviewing medical records. Examine claims flagged in the Advanced Rebill and Compliance queues, leveraging your knowledge of medical documentation and coding standards. Lead as a resource during system upgrades, acting as the liaison for testing and support and facilitating training on changes. Execute audits, develop tracking tools, and analyze data for identifying key issues and opportunities for retraining. Support internal departments with education on billing/coding standards and claims processing guidelines. Foster collaborative relationships across departments to achieve shared initiatives. Perform thorough research on complex claims, including clinical evaluations and coding research. Establish standards to communicate outcomes and facilitate performance tracking. Manage project plans for large initiatives, ensuring timely execution across teams. Contribute to quality improvement initiatives and compliance efforts. Document claims processing issues and escalate concerns appropriately. Conduct fraud, waste, and abuse audits, preparing detailed reports for management. Investigate billing and coding inquiries from various stakeholders and educate providers on refund processes. Lead special projects and committees, collaborating on cross-functional tasks. Work Experience: Minimum of 4 years in Level III claims adjudication or equivalent, demonstrating clinical knowledge and coding expertise. Education: High school diploma or equivalent required; Certified Professional Coder (CPC) preferred within 1 year. Knowledge: Strong understanding of PacificSource products, provider relationships, and healthcare insurance terminology is essential. Familiarity with healthcare regulatory trends and audit methodologies is beneficial. Environment: Offices are designed for ergonomic comfort, and travel is only required about 5% of the time. Physical Requirements: Ability to perform essential functions including sitting and standing for extended periods, typing, and lifting light materials. Salary Information: The compensation range for this role is $50,830.78 - $81,329.23, reflective of qualifications and experience.

Created: 2026-03-04