Department: Health Information Management
Reports To: Coding Supervisor
SUMMARY
The Coding Specialist is responsible for the accurate and timely review, abstraction, and assignment of diagnosis and procedure codes for outpatient and/or inpatient medical records. This position ensures compliance with ICD-10-CM, ICD-10-PCS, CPT, HCPCS, and applicable payer guidelines while supporting optimal reimbursement, data integrity, quality reporting, and regulatory requirements. The employee must maintain effective communication and good working relationships with the revenue cycle personnel, other departments, Medical Staff and the public, in conjunction with organization policies.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
- Review medical records and clinical documentation to assign accurate diagnosis and procedure codes.
- Abstract pertinent patient, physician, and clinical information into applicable information systems.
- Apply ICD-10-CM, ICD-10-PCS, CPT, and HCPCS coding guidelines according to official coding conventions and regulatory requirements.
- Ensure coding accuracy, completeness, and compliance with organizational policies and payer requirements.
- Identify documentation deficiencies and initiate appropriate and compliant physician queries when clarification is needed.
- Meet productivity and quality standards established by the organization.
- Collaborate with providers, clinical staff, CDI specialists, revenue cycle teams, and auditors to resolve coding issues.
- Support charge capture, reimbursement accuracy, and revenue integrity initiatives.
- Participate in internal and external coding audits and implement corrective actions when necessary.
- Maintain current knowledge of coding regulations, payer updates, and industry best practices.
- Attend continuing education sessions to maintain coding skills and active credentials.
- Assist with education and training related to coding compliance and documentation improvement.
- Protect patient confidentiality and comply with HIPAA and all applicable privacy regulations.
- Maintain coding accuracy and productivity standards established by the organization.
- Complete coding assignments within designated turnaround times.
- Participate in quality assurance reviews and continuous improvement activities.
- Demonstrate professionalism, teamwork, and commitment to organization values.
EDUCATION and/or EXPERIENCE
- Completion of an accredited coding program or equivalent coding experience.
- Knowledge of medical terminology, anatomy and physiology, disease processes, and pharmacology.
- Proficiency with electronic health records (EHR) and coding software.
- Strong analytical, organizational and problem-solving skills.
- Comprehensive understanding of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS coding systems.
- Knowledge of Medicare, Medicaid, and commercial payer requirements.
- Proficiency with Microsoft Office applications and healthcare information systems.
- One to three years of medical coding experience preferred.
CERTIFICATES, LICENSES, REGISTRATIONS
One or more of the following is preferred:
- Certified Coding Specialist (CCS),
- Certified Coding Specialist – Physician-Based (CCS-P),
- Certified Professional Coder (CPC),
- Certified Outpatient Coder (COC),
- Registered Health Information Technician (RHIT),
- Registered Health Information Administrator (RHIA).
PHYSICAL DEMANDS
While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel; and talk or hear. The employee is occasionally required to stand; walk; reach with hands and arms; climb or balance; and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.
WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is continuously exposed to noise, frequent eyestrain and restricted workstation. The employee is occasionally exposed to fumes or airborne particles.
Welia Health is an equal-opportunity employer.
