Medical Billing and Coding

• Reviews documentation and assigns appropriate ICD-10, CPT and HCPCS codes.
• Assigns appropriate primary diagnosis after deciding what was chiefly responsible for the encounter.
• Assigns appropriate modifiers according to guidelines.
• Finalizes the appropriate data for accounts.
• Clarifies documentation or diagnosis by communicating with the physician.
• Ensures weekly, monthly, and quarterly department goals are met.
• Makes recommendations to the Billing and Coding Manager for process and quality improvement.
• Maintains knowledge of current coding rules and trends for coding types assigned by attending seminars, workshops and watching webinars.

Medical Coder

• Independently perform complex, specialty-specific professional fee coding (CPT/HCPCS and ICD-10-CM) for physician services rendered in both office and hospital settings
• Ensure all coding adheres strictly to official guidelines (e.g., provided by AAPC or AHIMA), federal regulations (CMS), and organizational compliance standards
• Identify the need for formal clinical queries for documentation clarification when necessary for professional or facility records
• Maintain high accuracy and productivity standards appropriate to the complexity of the assigned workload
• May provide informal guidance to new coding staff on professional coding nuances

Coder II – Cardiology

• Provide accurate and timely revenue cycle and account management services
• Maintain compliance with payer requirements and engage in continuous process improvement
• Communicate effectively with team members and stakeholders

Medical Billing Specialist

• Independently perform complex, specialty-specific professional fee coding (CPT/HCPCS and ICD-10-CM) for physician services rendered in both office and hospital settings, ensuring expert application of modifiers and E/M guidelines
• Perform entry-level facility coding for simple outpatient encounters (e.g., diagnostic imaging, labs) and basic inpatient services (e.g., uncomplicated admissions, short stays) using ICD-10-CM and ICD-10-PCS, where applicable
• Ensure all coding adheres strictly to official guidelines (e.g., provided by AAPC or AHIMA), federal regulations (CMS), and organizational compliance standards
• Identify the need for formal clinical queries for documentation clarification when necessary for professional or facility records
• Maintain high accuracy and productivity standards appropriate to the complexity of the assigned workload
• May provide informal guidance to new coding staff on professional coding nuances

Coder II – ENT, Audiology

• Responsible for assisting the coding department with the day-to-day non-coding duties support activities
• Assigns codes to office-based visits and procedures using the International Classification of Diseases (ICD-10-CM), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS)
• Resolve coding edits to assure accurate and complete claims submission
• Sequences diagnoses and procedure codes as outlined in CPT, ICD-10-CM, and HCPCS Coding Guidelines while adhering to local and national governmental payer guidelines
• Reviews all clinician documentation to support assigned codes in the health information record
• Follows up and obtains clarification of inaccurate documentation as appropriate
• Codes risk adjustable encounters, resolves CRMs, and trends coding denials, as assigned
• Conducts formal coding and documentation reviews, clinician reviews and quality reviews, as assigned
• Assists with coding research functions and education activities
• Creates clinician coding and documentation education based on query trends or ad-hoc requests
• Adheres to the organization and departmental guidelines, policies, and protocols.
• Abides by Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.
• Practices ethical judgment in assigning and sequencing codes for proper insurance reimbursement
• Maintains confidentiality of patient.

Physician Support Coder

• Assign accurate CPT, HCPCS, and ICD-10 codes for all services performed at BHC facilities
• Apply appropriate modifier usage based on payer and service requirements
• Ensure documentation supports medical necessity, procedural complexity, and level of services
• Apply correct diagnosis sequencing and body-part specificity required for WC claims
• Support WC-specific documentation requirements, including injury dates. Causality, and treating physician narratives
• Collaborate with billing teams to ensure correct claim formats, attachments, and WC payer rules are met
• Ensure coding compliance with CMS, AMA, NCCI, and OIG guidelines
• Participate in internal and external coding audits , implement corrective actions as needed
• Identify coding trends that impact denials, underpayments, or compliance risk
• Provide feedback and education to provider to improve documentation and coding accuracy
• Assumes other responsibilities as appropriate to the position and organizational needs

Certified Medical Coder

• The Certified Medical Coder is responsible for accurate, compliant, and timely coding of professional and facility pain management services
• Assign accurate CPT, HCPCS, and ICD-10 codes for all services performed at BHC facilities
• Apply appropriate modifier usage based on payer and service requirements
• Ensure documentation supports medical necessity, procedural complexity, and level of services
• Apply correct diagnosis sequencing and body-part specificity required for WC claims
• Support WC-specific documentation requirements, including injury dates, causality, and treating physician narratives
• Collaborate with billing teams to ensure correct claim formats, attachments, and WC payer rules are met
• Ensure coding compliance with CMS, AMA, NCCI, and OIG guidelines
• Participate in internal and external coding audits, implement corrective actions as needed
• Identify coding trends that impact denials, underpayments, or compliance risk
• Provide feedback and education to provider to improve documentation and coding accuracy

Certified Medical Coder – Temporary Contract

• Evaluate medical records and provide clinical and surgical abstraction
• Accurately code diagnostic and procedural information
• Consult with medical providers for record clarification
• Ensure compliance with coding rules and regulations
• Compile reports and tabulate data from medical records
• Identify validation edits and ensure accurate coding
• Work independently under regular supervision

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