The Medical Coding and Documentation Specialist is responsible for determining the appropriate procedural and diagnostic codes to patient records, as well as performing analysis of the codes utilized by providers and ensuring documentation supports the codes selected. This staff member will also serve as a coding consultant to other Institute staff.

1. Communicates documentation and coding standards to employees and respond to questions across a wide spectrum of specialties that have diverse criteria for billing and coding.
2. Visually reviews and/or audits documentation to ensure appropriate codes are assigned in accordance with the state and governmental coding and auditing rules and regulations.
3. Assists with ongoing departmental and individual education sessions to improve CPT4 and ICD-10 coding accuracy and adherence to compliance standards.
4. Interacts with physicians and other patient care providers regarding billing and documentation policies, procedures, and regulations; obtains clarification of conflicting, ambiguous, or non-specific documentation.
5. Demonstrate knowledge of payer issues, documentation opportunities, clinical documentation requirements, and referral policies and procedures.
6. Inputs and maintains data on procedures required for state or other reporting.
7. Provides analysis of claim and/or appeal/denial issues, as needed.

QUALIFICATIONS:
 Coding certification (AHIMA and/or AAPC) required. Apprentice level certification considered.
 Certification in health care compliance is desirable.

EDUCATION:
 Associate’s degree in Healthcare Administration, Nursing, or other clinical degree required. .
 Bachelor’s degree in Healthcare Administration, Nursing, or other clinical degree preferred.

EXPERIENCE:
 1 year of relevant experience required.
 3 years of relevant experience preferred.