Professional Billing (PB) Auditor – Surgical Specialty
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
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