The Certified Coding Specialist will evaluate medical records and charges to ensure completeness, accuracy, and compliance with State and Federal Regulations and standardized coding guidelines.

Duties/Responsibilities:

• Evaluates medical record documentation and charging to optimize reimbursement by ensuring that diagnostic and procedural codes and other documentation accurately reflect and support the patient visit and ensure that data complies with legal standards and official coding guidelines.

• Responsible for assigning appropriate diagnosis and procedural coding to patient encounters according to official coding guidelines.

• Reviews state and federal Medicare reimbursement claims for completeness and accuracy before submission to minimize claim denial.

• Reads bulletins, newsletters, and periodicals and attends workshops to stay abreast of issues, trends, and changes in laws and regulations governing medical record coding guidelines and documentation.

• Educates and advises staff on proper code selection, documentation, procedures, and requirements as needed 

• Performs other related duties as assigned.

• Adheres to the facility’s Standards of Excellence.

Required Skills/Abilities: 

• Knowledge of diagnosis and procedural coding guidelines; medical terminology; anatomy and physiology; state and federal Medicare reimbursement guidelines; English grammar and usage.

• Ability to research and analyze data, draw conclusions, and resolve issues; read, interpret, and apply policies, procedures, laws, and regulations.

• Ability to read and interpret medical procedures and terminology. 

• Ability to exercise independent judgment; 

• Ability to maintain confidentiality.

Education and Experience:

• Must have an active Certified Coding Specialist (CCS) certificate; a Certified Coding Associate (CCA) certificate; a Registered Health Information Technician (RHIT) license; or a Registered Health Information Administrator (RHIA) license in good standing issued by the American Health Information Management Association.

• Must have coding experience, however education and training can be considered in leu of experience.

Physical Requirements: 

• Prolonged periods of sitting at a desk and working on a computer.

• Must be able to lift up to 15 pounds at times.