The Certified Coding Specialist is responsible for reviewing medical documentation and assigning accurate diagnosis and procedure codes for inpatient and outpatient facility services while ensuring compliance with ICD-10-CM/PCS, CPT, HCPCS, payer policies, and regulatory guidelines. This position also supports coding-related claim denials and front-end claim edits/rejections by identifying coding opportunities prior to claim submission and resolving post-adjudication coding issues. The ideal candidate possesses strong analytical skills, attention to detail, and the ability to work collaboratively with providers, CDI, billing, and revenue cycle teams to maximize coding accuracy and reimbursement.
Education & Certification
Required: Active CPC, COC, CCS, or CIC certification.
Preferred Qualifications
Experience coding both inpatient and outpatient facility accounts.
Experience reviewing coding-related denials and appeals.
Experience resolving front-end claim edits and payer rejections.
Knowledge of Medicare, Medicaid, and commercial payer reimbursement guidelines.
Experience using coding encoders and electronic medical record systems (e.g., 3M, TruCode, Epic, Meditech, Cerner).
Knowledge of DRG, APC, NCCI edits, and medical necessity guidelines.
Minimum Qualifications
2+ years of inpatient and/or outpatient facility coding preferred.
Strong knowledge of ICD-10-CM, ICD-10-PCS, CPT, HCPCS Level II, modifiers, DRGs/APCs.
Knowledge of NCCI edits, LCD/NCDs, CMS regulations, and Official Coding Guidelines.
Excellent communication and Microsoft Office skills.
Ability to prioritize work, meet deadlines, and work independently.
Primary Responsibilities – Front-End Coding
Review inpatient, outpatient, ED, observation, surgery, and ancillary records.
Assign accurate ICD-10-CM, ICD-10-PCS, CPT, HCPCS, and modifier codes.
Review coding edits and work queues prior to claim submission.
Validate documentation supports code assignment.
Query providers when documentation is incomplete or conflicting.
Review denials involving medical necessity, bundling, modifiers, DRGs/APCs, sequencing, and procedures.
Collaborate with CDI, billing, providers, and revenue integrity.
Monitor denial trends and recommend improvements.
Front-End Claim Rejections
Review coding-related claim rejections before adjudication.
Correct coding errors causing claim rejections.
Validate diagnosis/procedure combinations and modifier usage.
Partner with billing to reduce preventable rejections.
· Track recurring rejection trends.
Compliance & Quality
· Maintain HIPAA compliance.
Remain current on coding and payer updates.
Follow CMS, AHIMA, AAPC, AMA, and payer guidance.
Meet departmental productivity and QA expectations. (95% or greater)
Team Collaboration
Work with Coding Leadership, CDI, Revenue Cycle, Revenue Integrity, Billing, and Providers.
Assist with education, process improvement, and mentoring.
Communicate coding and payer updates to the team.
Preferred Areas of Experience
· Inpatient Facility Coding
· Outpatient Facility Coding
· Emergency Department Coding
· Observation
· Same-Day Surgery
· Infusion & Injection Coding
· Medical Necessity Reviews
· DRG Validation
· Revenue Integrity
· Coding Denials
· Claim Rejections
We are an Equal Opportunity Employer. All qualified applicants are considered for employment without regard to race, color, age, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by federal, state or local law.