The Manager of Medical Auditing is responsible for overseeing all coding audit activities across NeueHealth and Centrum Medical Holdings, ensuring accuracy, documentation integrity, and regulatory compliance in diagnosis and procedural coding throughout the enterprise. This role directs auditing practices for both wholly owned Centrum Medical Centers and non-wholly-owned Centrum-affiliated centers, integrating health plan feedback from external audits, conducting internal audit reconciliations, and collaborating with Compliance, Legal, and external vendors.

The scope of auditing extends beyond ICD-10-CM diagnosis coding to encompass CPT and HCPCS procedural coding, Evaluation and Management (E/M) leveling, and HCC / risk-adjustment capture, ensuring adherence to CMS, state Medicaid, HHS-HCC, and commercial payer documentation and coding guidelines. The Manager is expected to remain proactive in a continually evolving regulatory landscape — monitoring coding-model and policy changes (for example, CMS-HCC V28, RxHCC, and HHS-HCC updates) and translating them into refreshed audit protocols, education, and process improvements.

A core function of this role is to guide, educate, and train coders, providers, and clinical staff — converting audit findings into actionable feedback and sustainable performance improvement. The Manager partners closely with supervisors and organizational leadership to uphold the highest standards of coding compliance, efficiency, and accountability, and performs other duties as assigned in support of departmental and enterprise objectives.

This position carries enterprise-wide auditing responsibility and is expected to operate cross-functionally and flexibly as organizational needs evolve. The scope of the role includes, but is not limited to, the following:

• Audit coding and documentation across both wholly owned Centrum medical centers and non-wholly-owned Centrum affiliated centers, spanning Medicare Advantage, ACA/Exchange, and Medicaid lines of business.
• Audit the full range of coding — ICD-10-CM diagnosis, CPT and HCPCS procedural, E/M leveling, and HCC / risk-adjustment capture.
• Work in close, ongoing collaboration with the Manager of Medical Coding to align audit findings with coding operations, coder education, and evolving coding guidelines.
• Work in close, ongoing collaboration with the Manager of Revenue Cycle Management to connect audit outcomes to charge capture, claims accuracy, denials, and reimbursement integrity.
• Build and deliver audit workbooks, trackers, dashboards, and executive-facing presentations using advanced Microsoft Excel and PowerPoint skills.
• Assume additional tasks, projects, and responsibilities as needed to support leadership, compliance, and enterprise priorities.

DUTIES & RESPONSIBILITIES

The Manager, Medical Auditing job description is intended to point out major responsibilities within the role, but it is not limited to these items.

Audit Operations & Oversight

• Oversee and perform prospective, concurrent, and retrospective coding audits across both wholly owned Centrum medical centers and non-wholly-owned Centrum affiliated centers.
• Audit the full scope of coding — including ICD-10-CM diagnosis coding, CPT and HCPCS procedural coding, E/M leveling, and HCC / risk-adjustment capture — not limited to ICD processes and procedures alone.
• Validate that provider documentation supports all codes reported, applying accepted standards for documentation integrity and diagnosis support (e.g., MEAT).
• Reconcile internal audit results against external health plan and vendor audit findings; identify, quantify, and resolve discrepancies.
• Establish and maintain audit sampling methodologies, accuracy thresholds, and error-rate benchmarks, and track results and trends over time.

Compliance & Regulatory Integrity

• Ensure coding and auditing practices comply with CMS, state Medicaid, HHS/CMS risk-adjustment, and commercial payer requirements, as well as applicable federal, state, and local regulations.
• Proactively monitor OIG work plans, CMS transmittals, coding-model updates, and payer bulletins, and adjust audit protocols to reflect regulatory and model changes (e.g., CMS-HCC V28, RxHCC, HHS-HCC V08).
• Support RADV, Initial Validation Audit (IVA), and other regulatory and payer audit readiness and response activities.
• Identify, document, and escalate potential compliance risks — such as unsupported diagnoses, upcoding, cloned documentation, or credentialing/incident-to concerns — to Compliance and Legal.

Education, Training & Guidance

• Guide, educate, and train coders, providers, and clinical staff based on audit findings, coding updates, and identified opportunities.
• Develop and deliver feedback sessions, education materials, job aids, and corrective action plans that drive measurable improvement.
• Partner with supervisors and office managers to build ongoing curriculum and reinforce documentation and coding best practices across all centers.

Cross-Functional Collaboration

• Partner directly with the Manager of Medical Coding to translate audit findings into coding-operation improvements, coder education, and consistent application of coding guidelines.
• Partner directly with the Manager of Revenue Cycle Management to link audit results to charge capture, claim accuracy, denial prevention, and reimbursement integrity.
• Collaborate with Compliance, Legal, provider education, analytics, and health plan partners to align audit priorities with enterprise goals.

Reporting & Analytics

• Produce audit reports and executive summaries that quantify coding accuracy, error trends, impact, and remediation status.
• Build and maintain audit workbooks, trackers, and dashboards in Microsoft Excel (pivot tables, formulas, and large-dataset analysis), and develop executive-facing decks in Microsoft PowerPoint to present findings to leadership.
• Use data analysis tools to identify patterns, root causes, and opportunities for coding, documentation, and process improvement.

Proactivity & Other Duties

• Anticipate and adapt to changes in regulation, payer policy, and coding models, proactively updating auditing processes and procedures accordingly.
• Assume additional responsibilities and cross-functional tasks as needed, supporting other projects and priorities as directed by leadership.

EDUCATION AND PROFESSIONAL EXPERIENCE

(LICENSURES AND CERTIFICATIONS)

Certifications & Licensure

• Certified Professional Coder (CPC) — required.
• Certified Professional Medical Auditor (CPMA) required.
• Certified Risk Adjustment Coder (CRC) — required.
• Certified Documentation Expert Outpatient (CDEO), or equivalent — preferred.
• Active certification must be maintained in good standing through AAPC, AHIMA, or an equivalent credentialing body, including required continuing education units (CEUs).

Education & Experience

• Associate or bachelor’s degree in health information management, Healthcare Administration, or a related field preferred, or an equivalent combination of education and experience.
• Minimum of three (5) years' experience in medical coding, with a focus on auditing or a closely related role.
• Risk-adjustment / HCC coding and auditing experience strongly preferred, including exposure to Medicare Advantage, ACA/Exchange, and/or Medicaid lines of business.

Knowledge

• Extensive knowledge of ICD-10-CM, CPT, and HCPCS coding systems.
• Working knowledge of CMS-HCC, RxHCC, and HHS-HCC risk-adjustment models and RADV requirements.
• Strong understanding of medical terminology, anatomy, and physiology.
• Familiarity with electronic health record (EHR) systems, coding software, and audit tools.

Language Skills

• Bilingual proficiency in English and Spanish preferred.
• Strong written and verbal communication skills, with the ability to interpret and convey procedural documents, policies, and audit findings clearly and effectively.

Mathematical Skills

• Proficiency in calculating figures, percentages, error rates, and amounts related to coding, auditing, and billing processes.

Reasoning Ability

• Strong critical-thinking and analytical skills to address complex coding and documentation issues.
• Ability to interpret and implement payer-specific and regulatory guidelines effectively and consistently.

Other Skills & Abilities

• Advanced proficiency in Microsoft Excel (pivot tables, formulas, and data analysis) and Microsoft PowerPoint (executive-level presentations), with strong working proficiency in Word and Outlook.
• Experience with data analysis and reporting tools for auditing purposes.
• Strong time-management skills with the ability to handle multiple priorities and meet deadlines.

PROFESSIONAL COMPETENCIES

• Proven ability to work effectively in a culturally and professionally diverse environment.
• Demonstrates initiative, professionalism, and a commitment to continuous improvement.
• Maintains up-to-date knowledge of federal, state, and local compliance regulations and proactively applies changes.