Full-Time
Coding Auditor Educator-Inpatient
Posted on 9/19/2025
Highmark Health
5,001-10,000 employees
Health insurance plans and wellness resources
Compensation Overview
$27.36 - $42.41/hr
New Mexico, USA + 50 more
More locations: Washington, USA | Kansas, USA | Pennsylvania, USA | North Dakota, USA | Oregon, USA | Delaware, USA | Iowa, USA | California, USA | Washington, DC, USA | Vermont, USA | Wyoming, USA | Texas, USA | Montana, USA | Jackson Township, NJ, USA | Florida, USA | Waterbury, CT, USA | Nevada, USA | South Carolina, USA | South Dakota, USA | Georgia, USA | Arizona, USA | Concord, NH, USA | Mississippi, USA | Tennessee, USA | Virginia, USA | Arkansas, USA | Minnesota, USA | Colorado, USA | Nebraska, USA | Rhode Island, USA | Utah, USA | Kentucky, USA | West Virginia, USA | New York, NY, USA | Maryland, USA | Hawaii, USA | Wisconsin, USA | Maine, USA | Massachusetts, USA | North Carolina, USA | Oklahoma, USA | Missouri, USA | Ohio, USA | Indiana, USA | Louisiana, USA | Alaska, USA | Michigan, USA | Illinois, USA | Alabama, USA | Idaho, USA
Remote
 Medical, Clinical & Veterinary (2) |
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- High school diploma / GED
- Certification from American Academy of Professional Coders (AAPC) or American Health Information Management Association (AHIMA)
- 5 years with hospital or physician coding and/or auditing, as well as, education techniques and methods (Internal transfer and promotion candidates may have a minimum of 3 years experience)
- In-depth knowledge of ICD CM, ICD PCS and CPT/HCPCS coding systems
- Must be proficient in DRG/APC structure, National Correct Coding Initiatives, ICD CM/PCS Official Guidelines, Outpatient Prospective payment system and Coding Clinic references
- Current working knowledge of encoder, grouper, abstracting and other related software
- Strong analytical and communication skills
- Plans and conducts audits and reports on the documentation, coding and billing performed at AHN entities
- Reviews, develops and delivers training programs and educational materials to address deficiencies identified in the audits compliant with regulatory requirements
- Provides written audit guidance
- Participates with management in the assessment of external audit findings and responds as needed
- Attends meetings and interacts with management to resolve issues and provide advice on new programs
- Provides guidance to system entities in response to external coding audits conducted by the Medicare Administrative Contractor, the RAC, MIC, ZPIC, etc.
- Determine appeal action, prepare appeal letter follow up and identify education issues
- Develops audit detail summary spreadsheets and reports to address any coding, documentation, financial impact and profitability
- Conducts education/training or works with external resources to present final audit findings to department staff, physicians and appropriate individuals
- Validates the ICD-CM, ICD-PCS, CPT and HCPCS Level II code and modifier systems, missed secondary diagnoses and procedures and ensures compliance with DRG/APC structure and regulatory requirements
- Performs periodic claim form reviews to check code transfer accuracy from the abstracting system and the chargemaster
- Is responsible for or works with external resources to create and monitor inpatient case mix reports and the top 25 assigned DRGs/APCs in the facilities to identify patterns, trends and variations in the facilities frequently assigned DRG/APC groups
- Once identified, evaluate the cases of the change or problems and takes appropriate steps to effect resolution
- Reviews and interprets medical information, classifies that information into the appropriate payor specific groups consisting of ICD-CM ICD-PCS and CPT codes for diagnoses and procedures and calculates the DRG and APC
- Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and Corporate Compliance Coding Guidelines
- Assures compliance with the coding guidelines and regulatory requirements
- Performs other duties as assigned or required including training/mentoring of new staff, performing audits and research related to special projects and providing coverage for coding manager(s)
- Depending on location provides or arranges for education/training of facility healthcare professionals in use of coding guidelines and practices, proper documentation techniques, medical terminology and disease processes as it relates to the DRG/APC and other clinical data quality management factors
- With technical direction and assistance from management, designs and implements coder education program, continuing education programs and Medical Staff education programs
- Establishes and monitors performance and maintains appropriate documentation thereof
- Associate's Degree
- 3 years with claims processing and data management
- Past auditing and strong education/training background in coding and reimbursement
- Registered Health Information Associate (RHIA) credential
Highmark Health operates as a health insurer in Pennsylvania, Delaware, and West Virginia, serving individuals, families, businesses, and Medicare beneficiaries. Its plans are funded by premiums and, for eligible services, government reimbursements, covering doctor visits, hospital care, prescriptions, and preventive care, with member resources like symptom checkers and cost details. It differentiates itself through active community involvement and sustainability initiatives alongside a broad member base and Medicare/Medicaid compatibility. Its goal is to improve community health by providing thorough coverage and health resources while operating responsibly and sustainably.
Company Size
5,001-10,000
Company Stage
Grant
Total Funding
$29.6M
Headquarters
Pittsburgh, Pennsylvania
Founded
1996
Simplify's Take
What believers are saying
- Walk for Healthy Community 2026 benefits 150+ nonprofits at Point State Park.
- $1M Achieva grant launches home programs for children with complex needs.
- Living Health strategy integrates Noom into digital front door for members.
What critics are saying
- UPMC Health Plan mandates full documentation for surgeries from July 2025.
- Cigna's EviCore denies 7.7% Medicare Advantage requests, eroding relationships.
- Past phishing breach exposed 300,000 members' data in December 2022.
What makes Highmark Health unique
- Gold Card program grants 25,000 doctors instant prior authorizations since 2022.
- Noom partnership provides free weight management and diabetes programs to members.
- Abridge AI enables real-time prior authorization at point of care.
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Company News
Highmark Inc. has appointed Victor Fields as president and CEO of Highmark Wholecare, effective 1st June, succeeding Ellen Duffield who is retiring after leading the organisation since 2021. Fields will oversee the Medicaid and Medicare insurer, which serves 320,000 members in Pennsylvania. Fields brings extensive healthcare leadership experience, most recently serving as Health Plan CEO for UnitedHealthcare Community Plan of Minnesota, where he launched a new Medicaid, D-SNP and Affordable Care Act exchange marketplace entrant. He previously held CEO and CFO roles at HSC Health Care System. In his new role, Fields will lead organisational performance, including growth and quality of care, whilst maintaining strategic relationships with Pennsylvania state agencies, health systems, providers and community organisations.
Prior authorization can delay needed health care. A new 'Gold Card' targets that bottleneck. Kris B. Mamula Pittsburgh Post-Gazette Mar 22, 2026 Getting approval for a medical procedure scan or medicine has become a frustrating hurdle in health care as insurers try to ensure that every test is appropriate and that less costly alternatives have been tried first. Delays in getting medical care have sometimes resulted, critics say. "Across the country, physicians see firsthand the dangerous, harmful - and sometimes deadly - consequences of prior authorization," American Medical Association President Bruce A. Scott wrote in a 2024 survey of physicians about the issue. The AMA calls prior authorization a "blunt cost-control tactic," and Drew Altman, CEO of San Francisco-based health policy outfit KFF, recently said it was "public enemy number one for health care consumers." Now, Highmark has joined other insurers in creating a fast lane for doctors that allows instant pre-authorization for advanced imaging, certain surgeries and other procedures. For participating doctors, Highmark's Gold Card program eliminates the administrative costs of clinical documentation and appeals, thereby speeding care for patients. "It's meaningfully changing the patient experience for people that have Highmark insurance," said Donald Whiting, a neurosurgeon and chair of Allegheny Health Network's Neuroscience Institute. "The patient's experience with the payer or provider isn't always the best and anything we can do to improve the experience is a significant changemaker." An insurer's prior authorization request is an administrative headache that can take five hours per patient, he said. "The whole idea is not to get in the way between the doctor and the patient," said Tony Farah, chief medical and transformation officer at Highmark Health. "We believe that our model is the best one out there." Highmark introduced Gold Card in 2022 and last year announced that the easy pass for pre-authorization would soon be part of Downtown-based Abridge's ambient listening capabilities, which is used in Allegheny Health Network doctors' offices. Ambient listening translates physician-patient interactions into a medical record, saving doctors time and an administrative headache. Pre-authorization is a utilization and cost-saving feature of virtually every health insurance product - commercial, Medicaid, Obamacare, Medicare Advantage, and even traditional fee-for-service Medicare starting in six states this year. Even though the number of prior-authorization determinations fell slightly to 1.7 from 1.8 per Medicare Advantage plan enrollees between 2023 and 2024, the reviews overall were up 43.2% to 52.8 million between 2019 and 2024, driven mostly by enrollment increases in the for-profit Medicare plans, according to KFF. The pre-authorization reviews for Medicare Advantage plan members in 2024, for example, resulted in 4.1 million or 7.7% of the requests for coverage fully or partially denied by the insurer, up from 6.4% in 2023, according to KFF. Highmark contracts with third-party vendor Franklin, Tenn.-based EviCore by Evernorth to determine the appropriateness of sophisticated imaging such as MRIs and CT scans and many other medical procedures and prescription drugs. EviCore is owned by health insurance giant Cigna. EviCore advertises a 3-to-1 return on health care claim expenditures for insurers, which has led to physician complaints about prioritizing cost savings over clinical judgment. Highmark is relying less on this service by gradually bringing the review capability in-house, Dr. Farah said. Highmark-affiliated doctors can also apply for fast-track pre-authorization approval for many medical procedures, which bypasses the clinical documentation usually required. So far, nearly 25,000 doctors across Highmark's four-state footprint have qualified for Gold Card status, with a pre-authorization approval rate of 99%, Dr. Farah said. To qualify, doctors must have a high approval rate on previous pre-authorization requests and undergo a six-month trial period of working closely with the insurer, when they become familiar with program criteria and clinical guidelines for care, Dr. Farah said. "It's been very well received," he said. "It's faster care." In a notice to doctors in July, UPMC Health Plan enhanced its pre-authorization approval process for hip, knee and shoulder surgeries by reminding doctors to submit complete medical record documentation to support the medical necessity for procedures. "Our system has been updated to confirm the submission of such information before an authorization will be provided beginning July 24, 2025," according to the notice. Health plan officials did not return requests for comment on its pre-authorization policy. Highmark was among more than 50 that voluntarily agreed last year to streamline and simplify pre-authorizations. The changes will benefit some 257 million Americans by reducing the number of procedures that require prior approval before payment by insurers. The pre-authorization easy pass might also give Highmark a competitive edge in the health insurance marketplace, according to Dan Destefano, vice president of Green Tree broker Liberty Insurance Agency. "It expedites the pre-authorization process," he said. "It's exciting and it's about time." First Published: March 22, 2026, 1:00 a.m. Kris B. Mamula has been a health care business reporter for the Post-Gazette since 2015. A Carnegie Mellon University graduate, he was part of the team that won a Pulitzer Prize for coverage of the synagogue shooting in 2018.
Highmark Center wins MBA Building Excellence award. 27 Feb 2026 Carnegie Mellon University's Highmark Center for Health, Wellness and Athletics received recognition for its response to a complex site and program at Pittsburgh's largest construction award ceremony. The Master Builders' Association (MBA) recently hosted its Building Excellence Awards, a celebration that recognizes "outstanding achievement and exceptional craftsmanship" in regional projects, during their annual Construction Industry Evening of Excellence. Held at Acrisure Stadium, Carnegie Mellon University's Highmark Center for Health, Wellness and Athletics was the winner in the New Construction Over $50 Million category. While primarily new construction, the Highmark Center includes the integration and reuse of 24,000 GSF of the historic Skibo Gymnasium, originally designed by architect Henry Hornbostel in 1924. Faced with significant site-related challenges-including a shallow rock ledge under the site, a restricted height limit, and aging existing structures-the design and construction team, along with members of CMU's Campus Design and Facility Development, worked in tandem to address these obstacles and deliver a comprehensive and welcoming facility for the University's students. The Highmark Center is a meaningful response to the critical need to advance health and wellness support for students on campus. The project integrates CMU's University Health Services, Counseling and Psychological Services, Wellness Initiatives, Religious and Spiritual Life Initiatives, and Athletics, ensuring students have access to the support they need to thrive. The project caps a 15-year planning process that brought together stakeholders from across the university. Congratulations to its clients, Carnegie Mellon University, and construction team led by Mascaro Construction with photography by Nic Lehoux and Ed Massery.
Achieva receives $1 million grant from Highmark to launch program for children with complex medical needs. New initiative will keep families together by serving children with complex medical needs at home instead of pediatric medical care facilities. Pittsburgh, PA - Achieva, a leading disability services organization serving more than 10,000 Pennsylvanians annually, announced it has received a $1 million grant from Highmark to launch a comprehensive home transition program for children with complex medical needs. The program addresses a critical gap for families in Pennsylvania's healthcare system, where hundreds of children with disabilities and complex medical conditions currently live in hospitals or pediatric extended care facilities instead of homes with their families. These children face long-term institutionalization due to limited access to consistent and appropriate caregiving, financial constraints, complex government regulations, and gaps in service coordination. "Every child deserves to grow up in a loving family environment, not in a hospital room," said Steve Suroviec, President and CEO of Achieva. "This generous support from Highmark will allow us to build service capacity and remove barriers that keep medically complex children separated from their families, creating a clear pathway home." Research consistently shows that children thrive best when living with families rather than in institutional settings, with improved developmental outcomes and stronger family bonds. However, transitioning these children home (or keeping them home in the first place) often requires intensive case management by a nurse, home-based medical equipment and technology, respite for the parents or caregivers, and expensive home modifications, while government funding frequently moves too slowly or falls short of actual needs. Achieva's new program will provide comprehensive support including: * Expert case management and clinical oversight * Rapid problem-solving without bureaucratic delays * Direct funding for critical home modifications * Technology and medical equipment support * Coordinated care through a dedicated medical director and specialized staff "Highmark is proud to support Achieva's innovative approach to keeping families together," said Kenya T. Boswell, senior vice president of Community Affairs for Highmark Health and President of the Highmark Foundation. "This program represents exactly the kind of community-based solution that can transform lives while reducing long-term healthcare costs." The initiative is part of Achieva's Beyond Boundaries campaign, which aims to expand services and support more Pennsylvanians with disabilities to lead lives of personal significance. The program will serve as a coordinating model that eliminates the stress families currently experience navigating multiple agencies, forms, and approval processes while their children remain in institutional settings. Achieva expects the program to significantly reduce unnecessary institutional placements while strengthening family bonds and improving developmental outcomes for some of the community's most vulnerable children. For more information about Achieva, visit SupportBrightFutures.org. About Achieva: Achieva supports more than 10,000 Pennsylvanians with disabilities annually through housing, caregiving, employment, and advocacy programs. The organization is dedicated to supporting people with disabilities to lead lives of personal significance in their communities. An independent licensee of the Blue Cross Blue Shield Association, Highmark Inc., together with its Blue-branded affiliates, collectively comprise the fifth largest overall Blue Cross Blue Shield-affiliated organization in the country with more than 7 million members in Pennsylvania, Delaware, West Virginia and western and northeastern New York. Its diversified businesses serve group customer and individual needs across the United States through dental insurance and other related businesses. For more information, visit www.highmark.com.
Carnegie Mellon University wins Silver Award at COAA Connect 2025 for the Highmark Center for Health, Wellness and Athletics. November 12, 2025 PMWEB congratulates Carnegie Mellon University for receiving the Silver Award at the Construction Owners Association of America (COAA) Connect 2025 Conference. The award honors outstanding achievement in project delivery and recognizes the university's success in completing the Highmark Center for Health, Wellness and Athletics: a 160,000-square-foot facility that brings together health services, counseling, athletics, and wellness under one roof. The $80.7 million Construction Manager-at-Risk (CMAR) project combined the renovation of a historic gymnasium with a modern new addition, transforming the space into a holistic hub for student well-being. Sustainable design elements and salvaged materials were integrated throughout, reflecting the university's commitment to environmental stewardship and long-term campus resilience. What is Construction Manager-at-Risk (CMAR)? The CM-at-Risk delivery method is a project approach that balances cost control, collaboration, and schedule performance. In CMAR, the owner hires a construction manager during the design phase who commits to delivering the project within a Guaranteed Maximum Price (GMP). This method allows the CM to provide input on constructability, cost, and scheduling early in the process, while still maintaining competitive procurement for trade contracts. For Carnegie Mellon, this approach enabled tighter alignment between design intent and execution, greater cost predictability, and improved communication between the owner, architect, and contractor. By unifying all stages of the project in a centralized platform, CMU ensured that these outcomes were achieved with total control. A Model for Complex Capital Project Delivery Carnegie Mellon used PMWEB to manage every phase of the Highmark Center project. By centralizing data across stakeholders - including the CM - the university's project team maintained transparency, minimized risk, and ensured that every decision aligned with the project's strategic and financial goals. This award builds on the university's long-standing commitment to innovation in capital project delivery. The Facilities Management and Campus Design (FMCS) team uses PMWEB to streamline project controls, improve reporting, and strengthen accountability across their portfolio of major capital initiatives. PMWEB is a system that was really designed for construction project management on the owner's side. And it was developed by people who really understood that process. Tom Truong, Financial Systems and Analytics Manager A Win for the Future of Campus Development The Highmark Center for Health, Wellness and Athletics is a statement about how leading universities are rethinking capital programs to support the student experience. PMWEB is proud to empower institutions like Carnegie Mellon University with the tools to plan, manage, and deliver complex projects that shape the next generation of learning environments. Read more about how PMWEB supports Carnegie Mellon University in crafting project management success.