Professional Billing (PB) Auditor - Surgical Specialty

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

Required Qualifications:

• Minimum 3+ years of professional billing auditing experience with a focus on surgical services
• Active CPC, CCS-P, or equivalent coding certification required
• Strong knowledge of CPT (Surgery section), ICD-10-CM, modifiers, and NCCI edits
• Experience auditing hospital-based physician surgical billing claims
• Strong written and verbal communication skills with the ability to provide constructive audit feedback

Preferred Specialty Background:

• Experience auditing complex specialty encounters in one or more of the following areas:
  
  • Complex Orthopedic Surgery (beyond routine joint replacement/fracture care)
  • Hematology / Oncology
  • OB/GYN, Maternal-Fetal Medicine, or Maternal-Newborn Services (including familiarity with maternal vs. newborn chart distinctions)
• CPMA credential or Epic EHR experience