Clinical Documentation & Coding Specialist
Synapticure Inc.
full-time
Posted on:
Location Type: Remote
Location: Remote • Illinois • 🇺🇸 United States
Visit company websiteJob Level
JuniorMid-Level
About the role
- Perform comprehensive chart preparation for dementia-care patients by reviewing multi-year clinical histories, consult notes, diagnostics, medication lists, and hospital records.
- Identify suspected, undocumented, or insufficiently supported chronic conditions and prepare findings for provider review.
- Review medical records for documentation gaps, inconsistencies, or unclear diagnostic specificity and flag issues in advance of visits.
- Accurately assign ICD-10-CM codes in compliance with CMS HCC guidelines and official coding rules.
- Validate that all diagnoses meet MEAT documentation standards and are supported within the medical record.
- Review post-visit documentation to reconcile diagnoses, address missed opportunities, and provide coding recommendations.
- Query providers for clarification when documentation is incomplete, ambiguous, or inconsistent, ensuring compliant query practices.
- Provide feedback and education to providers on documentation needs for accurate HCC capture.
- Collaborate with revenue cycle, CDI, and auditing teams to close documentation gaps and improve workflows.
- Maintain high accuracy and productivity benchmarks in both chart prep and coding.
- Participate in internal and external audits and implement corrective actions as needed.
- Stay current with CMS, HHS, and payer-specific risk adjustment updates, especially those impacting neurology and dementia care.
- Ensure CPT/HCPCS/ICD-10 coding for encounter-based services is accurate, compliant, and ready for timely claim submission.
Requirements
- High school diploma required; Associate’s or Bachelor’s degree in a health-related field preferred.
- Active **CPC** or **CCS** certification (AAPC or AHIMA).
- **CRC certification strongly preferred.**
- 2–3+ years of medical coding experience, including 1–2 years in HCC/risk adjustment.
- Demonstrated experience performing detailed pre-visit chart preparation.
- Experience coding neurology, psychiatry, behavioral health, or dementia conditions (strongly preferred).
- Strong understanding of ICD-10-CM, HCC models, MEAT criteria, and CMS/HHS risk adjustment principles.
- Ability to analyze medical records, identify unsupported diagnoses, and detect coding gaps.
- Excellent communication skills for provider interaction and compliant query writing.
- Proficiency with coding software, EHR platforms, and technology tools.
- Ability to work independently, maintain accuracy under volume, and meet tight deadlines.
Benefits
- Competitive salary based on experience
- Comprehensive medical, dental, and vision coverage
- 401(k) plan with employer match
- Remote-first work environment with home office stipend
- Generous paid time off and sick leave
- Professional development and career growth opportunities
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
ICD-10-CM codingCPT codingHCPCS codingHCC codingmedical codingchart preparationdocumentation analysisrisk adjustmentMEAT criteriacoding recommendations
Soft skills
communication skillsanalytical skillsattention to detailindependencetime managementcollaborationfeedback provisioneducational skillsproblem-solvingadaptability
Certifications
CPCCCSCRC