Healthcare Coding Specialist

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Position Summary
The Healthcare Coding Specialist is responsible for accurately reviewing, assigning, and validating medical diagnosis and procedure codes for physician and non-physician provider services. This position ensures compliance with ICD-10-CM, CPT, HCPCS Level II, Medicare, commercial payer, and regulatory requirements while supporting timely claim submission, accurate reimbursement, quality reporting, and organizational compliance.

The Coding Specialist works collaboratively with providers, clinical staff, billing personnel, and leadership to improve documentation quality, reduce claim denials, and maintain coding integrity.

Medical Coding
o Review provider documentation for completeness and coding accuracy.
o Assign appropriate ICD-10-CM, CPT, and HCPCS Level II codes.
o Verify that documentation supports all reported diagnoses and procedures.
o Apply current CMS, Medicare, and commercial payer coding guidelines.
o Ensure appropriate sequencing of diagnoses and procedures.
o Maintain coding accuracy for Evaluation and Management (E/M) services.
o Apply modifiers correctly according to payer-specific guidelines.
o Identify opportunities to improve documentation that supports appropriate coding.

Documentation Review
o Review medical records for sufficient clinical documentation.
o Query providers when clarification or additional documentation is needed.
o Assist providers in improving documentation to accurately reflect patient complexity and medical necessity.
o Monitor documentation trends and recommend process improvements.

Compliance
o Maintain compliance with HIPAA, CMS, OIG, and payer regulations.
o Stay current with annual coding updates and regulatory changes.
o Participate in internal coding audits and compliance reviews.
o Assist with external audit requests and documentation retrieval.
o Identify coding trends that may present compliance risks.

Revenue Cycle Support
o Work closely with billing staff to resolve coding-related claim edits and denials.
o Research rejected or denied claims related to coding issues.
o Recommend corrective actions to reduce future denials.
o Assist in implementing payer-specific coding requirements.
o Support timely claim submission and reimbursement.

Quality Improvement
o Monitor coding accuracy metrics.
o Participate in coding education for providers and clinical staff.
o Assist with quality reporting initiatives including MIPS, Medicare Advantage, HEDIS, RAF/HCC, and other value-based care programs as applicable.
o Support organizational initiatives related to documentation improvement and clinical quality.

Administrative Responsibilities
o Maintain coding references and educational materials.
o Attend departmental meetings and continuing education.
o Maintain required coding certifications.
o Perform other duties as assigned.
Knowledge/Skills/Abilities
o Strong understanding of physician documentation requirements.
o Knowledge of Evaluation and Management (E/M) coding guidelines.
o Familiarity with HCC/RAF risk adjustment coding.
o Excellent analytical and critical thinking skills.
o Strong attention to detail and accuracy.
o Ability to interpret complex medical documentation.
o Excellent written and verbal communication skills.
o Ability to prioritize multiple projects while meeting deadlines.
o Ability to maintain confidentiality.
o Strong organizational and time-management skills.
o Ability to work independently and as part of a multidisciplinary team.

Required Qualifications
o High school diploma or equivalent required.
o Associate degree in Health Information Management or related field preferred.
o Minimum of two (2) years of physician office coding experience.
o Experience coding primary care, family medicine, or internal medicine preferred.
o Thorough knowledge of ICD-10-CM, CPT, and HCPCS coding systems.
o Working knowledge of Medicare, Medicaid, and commercial payer requirements.
o Experience using Electronic Health Record (EHR) systems.
o Proficiency with Microsoft Office applications.

Preferred Certifications (one or more of the following:)
o Certified Professional Coder (CPC)
o Certified Coding Specialist (CCS)
o Certified Outpatient Coder (COC)
o Certified Risk Adjustment Coder (CRC)
o Registered Health Information Technician (RHIT)

Physical Requirements
o Prolonged periods of sitting and computer use.
o Ability to read detailed medical documentation.
o Ability to communicate effectively by telephone, video conference, and in person.
o Occasionally lift up to 20 pounds.

Work Environment
o Office or clinical environment.
o Hybrid or remote work may be available based on organizational needs.
o Frequent interaction with providers, clinical staff, billing personnel, and administrative leadership.

Performance Expectations
The Healthcare Coding Specialist will be evaluated on:
o Coding accuracy
o Productivity standards
o Documentation improvement initiatives
o Claim denial reduction
o Compliance with coding regulations
o Timeliness of coding completion
o Provider education effectiveness
o Collaboration with revenue cycle and clinical teams

Reports To: Revenue Cycle Manager, Billing Manager, or Practice Administrator

Equal Employment Opportunity

Woodlands Diagnostic Clinic is an Equal Opportunity Employer and is committed to providing a workplace free from discrimination and harassment. Employment decisions are based on qualifications, merit, and organizational needs.

Knowledge of Evaluation and Management (E/M) coding guidelines.
Knowledge of HCC/RAF risk adjustment coding.
Knowledge of ICD-10-CM, CPT, and HCPCS Level II codes.
Knowledge of current CMS, Medicare, and commercial payer coding guidelines.
Knowledge of appropriate sequencing of diagnoses and procedures.
Experience in a Primary Care/Internal Medicine/Family Medicine environment.
Experience with Value-Based Care performance requirements.
Experience with NextGen EHR system.

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