Medical Billing and Coding

• Assign appropriate diagnosis codes (ICD-10) and procedure codes (CPT/HCPCS) to patient encounters
• Ensure compliance with coding guidelines, including those outlined by the AMA, CMS, and other regulatory bodies
• Analyze medical records to extract pertinent information for coding purposes
• Maintain a high level of accuracy and quality in coding assignments
• Utilize coding software, encoders, and electronic health record systems
• Support coding compliance efforts by participating in coding audits and internal or external coding reviews
• Maintain accurate records of coding activities

Coding Specialist II

• Code medical records to validate ICD-10-CM codes for PACE Risk Adjustment
• Meet department production and quality standards
• Research regulatory guidelines for supporting documentation
• Prepare coding reports using excel
• Prepare oral and/or written reports of work activity to Supervisor
• Be responsible and accountable for maintaining the confidentiality, integrity, and availability of protected health information.
• Follow HIPAA security policies and procedures affecting your job, and report any suspected or actual violation or breach
• Other duties as assigned

Risk Adjustment Coder

• Assign appropriate codes to reflect all diagnoses and procedures extrapolated from physician documentation
• Abstract required data to input into the Medical Center's computerized database
• Converts patient visits into appropriate DRG assignments
• Review patient medical records and abstract medical data
• Code diagnoses, procedures, and appropriate modifiers
• Assign grouper codes to each record
• Enters coded/abstracted information in grouper
• Maintain accuracy rate of 95% or better
• Maintain productivity standards
• Assist in training new personnel in department coding procedures

HIM Coder

• Analyze operational and workflow data to identify inefficiencies, root causes, and opportunities for process improvement within the Medical Coding Automation product.
• Design and recommend scalable solutions that prioritize automation, AI-enabled workflows, and operational efficiency over manual processes.
• Collaborate cross-functionally with Product, Operations, Commercial, and R&D teams to support implementation of workflow enhancements.
• Create and maintain project plans, presentations, stakeholder communications, and performance metrics to support transparency and execution.
• Ensure adherence to medical coding standards, compliance guidelines, and coding quality expectations across workflows and operational processes.

Senior Medical Coding Automation Associate

• Perform complex coding for CPT, HCPCS, and ICD-10 with a focus on high-impact, payer-sensitive services
• Lead expansion and validation of new and underutilized codes (e.g., 90785, T1016, G-codes, state-specific Medicaid codes)
• Apply and validate advanced modifier usage, including Medicaid and MCO-specific requirements, to ensure accurate reimbursement
• Conduct deep-dive research on payer policies, fee schedules, and billing requirements across Medicaid, MCOs, and commercial plans
• Establish coding standards and best practices across the organization
• Serve as the subject matter expert (SME) for coding logic in automation and AI initiatives
• Translate complex coding rules into scalable system logic for upstream claim automation
• Perform manual chart reviews using Medical Decision Making (MDM) guidelines
• Validate appropriate E/M level selection
• Identify opportunities for appropriate upcoding where documentation supports higher acuity
• Establish a 'gold standard' baseline for CPT coding accuracy
• Lead analysis of coding-related denials and rejections, including diagnosis and modifier-related issues
• Identify root causes and drive upstream fixes to prevent recurrence
• Provide expert guidance on complex denial scenarios and appeals strategy, particularly for Medicaid and MCO plans
• Support review of payment discrepancies (paid vs. expected based on fee schedules)
• Provide coding insight into payer behavior and reimbursement variances across Medicaid and MCOs
• Work closely with Clinical teams to ensure documentation supports coding accuracy
• Partner with RCM leadership on billing strategy and optimization initiatives
• Support training and documentation (e.g., SOPs, internal knowledge base content)

Medical Coder – Medicaid, Behavioral Health

• Conduct insurance verifications to understand patient insurance benefits and document in EHR
• Collaborate with behavioral health providers as needed and obtain outstanding documentation
• Review electronic remittance advice (ERA) to reconcile with insurance and patient balances
• Monitor and follow up on unpaid, underpaid, or denied claims, including appeals and resubmissions, to ensure timely reimbursement and resolution of payment issues
• Work closely with clinicians and leadership to resolve errors
• Send patient statements, settles patient balances and manage patient payment plans
• Place outbound calls to patients regarding past due balances or defaulted payment plans
• Take inbound calls and emails from patients regarding account questions
• Review patient credit balances and process refunds as needed
• Uphold patient confidentiality and adhere to all HIPAA (Health Insurance Portability and Accountability Act) regulations in handling and protecting sensitive behavioral health information
• Report regularly on assigned responsibilities including A/R, trends, payments, balances, and claim errors
• Performs other duties as assigned

Medical Billing & Revenue Cycle Lead

• Conduct insurance verifications to understand patient insurance benefits and document in EHR
• Collaborate with behavioral health providers as needed and obtain outstanding documentation
• Review electronic remittance advice (ERA) to reconcile with insurance and patient balances
• Monitor and follow up on unpaid, underpaid, or denied claims, including appeals and resubmissions
• Work closely with clinicians and leadership to resolve errors
• Send patient statements, settle patient balances and manage payment plans
• Place outbound calls to patients regarding past due balances or defaulted payment plans
• Take inbound calls and emails from patients regarding account questions
• Review patient credit balances and process refunds as needed
• Uphold patient confidentiality and adhere to all HIPAA regulations
• Report regularly on assigned responsibilities including A/R, trends, payments, balances, and claim errors

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Coding Specialist II

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Medical Billing & Revenue Cycle Lead