Coding and Documentation Specialist

Overview

The Remote Medical Record Quality Auditor, under the supervision of the Coding & Documentation Supervisor, is responsible for ensuring high quality accurate medical record documentation reviews, coding reviews, training, and education for Forefront physicians, NP’s, PA’s. This individual must have strong communication and critical thinking skills. Dedication to consistent professionalism and teamwork is required. 

Responsibilities

• Conducts coding and documentation audits across general and surgical dermatology, plastic surgery, and pathology services.  Analyzes data, identifies trends, determines root causes, and implements corrective action plans to mitigate compliance and financial risk.
• Interprets and applies complex coding regulations (CPT, ICD-10, HCPCS) and payer guidelines, exercising independent judgment to resolve ambiguous or high-risk coding scenarios.
• Serves as a subject matter expert by advising providers and leadership on coding practices, documentation standards, and regulatory requirements.
• Designs and delivers targeted education programs for physicians and advanced practice providers based on audit findings, risk areas, and organizational priorities.
• Develops and maintains coding procedures, policies, and training materials to ensure alignment with evolving regulatory and payer requirements.
• Supports revenue cycle operations by resolving complex coding issues, including claim edits, denials, and appeals, and escalating compliance risks as appropriate.
• Supports onboarding and integration of new practices, including due diligence coding assessments, and provides actionable recommendations to improve operational, compliance, and financial outcomes.

Qualifications

• Associate's degree preferred, or equivalent combination of education, training, and experience.
• 2 + years of progressive experience in medical auditing, or documentation improvement; dermatology outpatient coding experience strongly preferred. 
• In-depth knowledge of evaluation and management (E&M) coding and demonstrated ability to interpret regulations and apply independent judgment in complex coding and compliance scenarios.
• Experience developing training programs, policies, or audit methodologies preferred.
• Strong analytical, critical thinking, problem-solving, and time management skills, with the ability to prioritize competing deadlines and maintain productivity.
• Excellent communication skills, including the ability to educate physicians and provide constructive feedback on documentation and coding practices.
• Proficiency in electronic health record (EHR) systems (NextGen, EMA preferred) and Microsoft Office applications, with the ability to manage multiple priorities and drive projects to completion.
• Other Licensures or Certifications not Listed: CPCD, CPC, CCS, CBCS, or CPMA or equivalent.

 

Physical Demands

• Sitting for extended periods
• Manual dexterity for typing and computer use
• Visual acuity for reading screens and documents
• Verbal communication via phone or in person

For this position, the base pay range is $62,000 - $67,000 per year. Individual pay is determined by role, level, location, job-related skills, experience, and relevant education, certifications, or training.

Forefront Dermatology is committed to providing equal employment opportunity and maintaining a workplace for employees and applicants that is free from discrimination based upon age, race, religion, color, disability, marital status, sex (including pregnancy), national origin, ancestry, ethnicity, sexual orientation, gender identity or expression, genetic information, veteran or military status, or any other status protected by applicable federal, state, or local law. If, because of a medical condition or disability, you need a reasonable accommodation for any part of the application process, please contact [email protected] to let us know the nature of your request and your contact information.

• Associate's degree preferred, or equivalent combination of education, training, and experience.
• 2 + years of progressive experience in medical auditing, or documentation improvement; dermatology outpatient coding experience strongly preferred. 
• In-depth knowledge of evaluation and management (E&M) coding and demonstrated ability to interpret regulations and apply independent judgment in complex coding and compliance scenarios.
• Experience developing training programs, policies, or audit methodologies preferred.
• Strong analytical, critical thinking, problem-solving, and time management skills, with the ability to prioritize competing deadlines and maintain productivity.
• Excellent communication skills, including the ability to educate physicians and provide constructive feedback on documentation and coding practices.
• Proficiency in electronic health record (EHR) systems (NextGen, EMA preferred) and Microsoft Office applications, with the ability to manage multiple priorities and drive projects to completion.
• Other Licensures or Certifications not Listed: CPCD, CPC, CCS, CBCS, or CPMA or equivalent.

 

Physical Demands

• Sitting for extended periods
• Manual dexterity for typing and computer use
• Visual acuity for reading screens and documents
• Verbal communication via phone or in person

For this position, the base pay range is $62,000 - $67,000 per year. Individual pay is determined by role, level, location, job-related skills, experience, and relevant education, certifications, or training.

• Conducts coding and documentation audits across general and surgical dermatology, plastic surgery, and pathology services.  Analyzes data, identifies trends, determines root causes, and implements corrective action plans to mitigate compliance and financial risk.
• Interprets and applies complex coding regulations (CPT, ICD-10, HCPCS) and payer guidelines, exercising independent judgment to resolve ambiguous or high-risk coding scenarios.
• Serves as a subject matter expert by advising providers and leadership on coding practices, documentation standards, and regulatory requirements.
• Designs and delivers targeted education programs for physicians and advanced practice providers based on audit findings, risk areas, and organizational priorities.
• Develops and maintains coding procedures, policies, and training materials to ensure alignment with evolving regulatory and payer requirements.
• Supports revenue cycle operations by resolving complex coding issues, including claim edits, denials, and appeals, and escalating compliance risks as appropriate.
• Supports onboarding and integration of new practices, including due diligence coding assessments, and provides actionable recommendations to improve operational, compliance, and financial outcomes.