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Description
Position Overview
The Professional Billing (PB) Auditor – Surgical Specialty provides ongoing audit support for hospital-based physician billing with a focus on complex surgical services. This role is responsible for auditing professional fee claims to ensure accurate coding, regulatory compliance, and risk mitigation, while supporting continuous improvement and education for coding staff.
Key Responsibilities:
Perform retrospective and/or concurrent audits of
professional billing surgical claims
Review operative reports and supporting documentation to validate appropriate CPT, HCPCS, and ICD-10-CM code assignment
Validate modifier usage and bundling in accordance with NCCI edits and payer guidelines
Identify surgical coding trends, compliance risks, and opportunities for improvement
Provide clear, educational feedback to professional billing coders related to
surgical coding accuracy
Document audit findings and recommendations in accordance with established audit standards
Support internal and external audit preparedness related to professional fee surgical services
Ensure compliance with CMS, AMA, and payer-specific billing regulations
Requirements
Qualifications:
Minimum
2+ years of professional billing auditing experience
with a focus on
surgical services
Strong knowledge of CPT (Surgery section), ICD-10-CM, modifiers, and NCCI edits
Experience auditing
hospital-based physician surgical billing
claims
CPC, CPMA, or equivalent certification preferred
Strong written and verbal communication skills with the ability to provide constructive audit feedback