Certified Medical Coder

The Medical Coding Specialist is responsible for reviewing clinical documentation and assigning accurate diagnosis, procedure, and quality-reporting codes in accordance with current U.S. coding guidelines, payer requirements, and applicable documentation standards. This position supports accurate claim preparation, risk-adjustment reporting, documentation quality, and regulatory compliance. The ideal candidate is detail-oriented, knowledgeable in U.S. medical coding, and able to work collaboratively with providers, practice staff, and internal teams to resolve documentation and coding questions.

Key Responsibilities

Medical Coding and Claim Accuracy Review encounter notes, consultations, discharge summaries, and other supporting medical records.

Assign accurate ICD-10-CM, CPT, HCPCS Level II, and applicable quality-reporting codes.

Enter validated codes into the practice’s EMR or billing system to support accurate claim preparation.

Apply current U.S. coding guidelines, payer requirements, and documentation standards.

Assign CPT Category II and other appropriate codes to support quality-measure reporting, when applicable.

Review relevant medical records to support accurate coding, continuity of care, and risk-adjustment reporting.

Documentation Review and Quality Assurance Identify incomplete, inconsistent, or unclear documentation and coordinate with providers and practice staff to obtain clarification.

Conduct prospective, concurrent, and retrospective coding and documentation reviews, as assigned.

Perform audits to evaluate documentation completeness, coding accuracy, and compliance.

Use approved source documentation to validate coding and quality-measure reporting.

Identify and report opportunities to improve clinical documentation, coding accuracy, and quality-reporting processes.

Support medical-record completion, quality initiatives, and departmental projects.

Collaboration and Professional Development Collaborate with supervisors, clinical staff, and other departments to resolve coding and documentation questions.

Assist in educating providers and office staff on documentation requirements and coding guidelines.

Maintain current knowledge of coding rules, payer requirements, and industry standards through continuing education and company-sponsored training.

Follow all company policies, confidentiality requirements, and applicable privacy and security procedures.

Participate in team meetings and contribute to responsive, professional client service.

Perform other related coding, documentation-review, audit, and quality-improvement responsibilities as assigned.

Bachelor’s degree or equivalent four-year college degree.

US medical coding experience.

Certified Professional Coder (CPC) credential through AAPC or an appropriate coding certification through AHIMA strongly preferred (current or expired).

Proficiency in assigning ICD-10-CM, CPT, and HCPCS codes based on provider documentation and applicable coding guidelines.

Knowledge of U.S. coding and documentation standards, payer requirements, Medicare risk adjustment methodology, and HEDIS quality measures.

Strong written and verbal English communication skills.

Excellent organizational, customer service, and problem-solving skills, with close attention to detail.

Ability to communicate effectively with providers, practice staff, insurance representatives, and internal teams.

Proficiency with Microsoft Word, Excel, email, payer portals, and electronic medical record (EMR) systems.