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 role ensures compliance with ICD-10-CM, ICD-10-PCS, CPT, HCPCS, and applicable payer guidelines while supporting reimbursement, data integrity, quality reporting, and regulatory requirements.
The position works closely with revenue cycle personnel, other departments, medical staff, and the public while maintaining effective communication and adherence to organizational policies.
Essential duties
- 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.
- Complete coding assignments within designated turnaround times.
- Participate in quality assurance reviews and continuous improvement activities.
- Demonstrate professionalism, teamwork, and commitment to organizational values.
Requirements & Qualifications
Education and 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.
Preferred credentials
- 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
- Regularly required to sit and use hands to finger, handle, or feel.
- Frequently required to talk or hear.
- Occasionally required to stand, walk, reach, climb, balance, stoop, kneel, crouch, or crawl.
- Must occasionally lift and/or move up to 25 pounds.
Location
Minnesota, US
Employment Type
Part-time
Experience Level
Associate
Remote work allowed
No
Posted
4 weeks ago
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