About This Role
This Coding Specialist I role focuses on independently reviewing, analyzing, and resolving all assigned front-end claims to ensure accurate and timely claim submission. The position identifies and corrects coding-related issues prior to claim transmission, applying established coding guidelines, payer requirements, and organizational policies. The specialist works closely with revenue cycle partners to prevent claim rejections, support clean claim rates, and promote efficient reimbursement processes.
Responsibilities
- Average 10 front-end holds per hour
- Maintain a minimum of 90% coding accuracy
- Assign ICD-10-CM and CPT codes with appropriate modifiers for services provided in the professional fee environment
- Review medical records and all applicable documentation to determine appropriate codes for documented services and diagnoses
- Ensure all diagnosis codes meet local and national medical necessity guidelines
- Utilize internal coding resources, payer guidelines, and other reference materials to ensure accurate and compliant coding for all assigned services
- Follow all HIPAA regulations and uphold the highest standards of privacy and confidentiality
- Maintain current knowledge of laws, regulations, payer policies, and industry guidance impacting compliant coding practices
- Independently review and resolve all assigned front-end claim holds
- Actively participate in department meetings, one-on-one meetings, and mentorship meetings with the assigned Coding Team Lead
- Escalate identified client trends to the assigned Coding Team Lead
- Escalate all coding-related questions to the assigned Coding Team Lead for guidance and clarification
- Maintain and complete all CEU requirements
- Perform other duties or tasks as assigned
Requirements
- Must hold a current AAPC or AHIMA Certification for a minimum of 3 years
- Strong working knowledge of CPT, ICD-10-CM, medical terminology, anatomy and physiology, and state and federal Medicare reimbursement guidelines
- Familiarity with proper English grammar, usage, and professional documentation standards
- Ability to research and analyze data, draw logical conclusions, and resolve coding or documentation issues
- Ability to read, interpret, and apply policies, procedures, laws, and regulations
- Ability to accurately read and interpret medical documentation, clinical terminology, and documented procedures
- Demonstrated ability to exercise independent judgment in coding and claim resolution
- Excellent written and verbal communication skills, including the ability to prepare reports, clarify documentation needs, and maintain collaborative working relationships with physicians and staff
