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

• Reviewing documentation and selecting the appropriate procedure and/or diagnosis code to be entered in billing documents
• Ensuring that teaching physician requirements are met and are clearly reflected in the documentation
• Other duties as assigned

Certified Coder – Practice Operations, Certified Professional Coder

• Responsible for primary diagnosis and procedural coding for designated ambulatory and hospital outpatient setting
• Responsible for proficiently assigning proper and accurate medical codes for diagnosis, procedures, and services performed in an outpatient setting, such as, but not limited to emergency department, outpatient clinics, same day surgeries, or diagnostic testing (radiology and laboratory)
• Typically reports to the Coding Manager
• Reviews medical record documentation to identify pertinent diagnosis/procedures that require code assignment for outpatient records and accurately codes the diagnoses and procedures using ICD-10-CM coding conventions for the purpose of reimbursement, research, and compliance with federal regulations.
• Reviews the medical record to assure specificity of diagnoses, procedures, and appropriate reimbursement for hospital and professional charges.
• Queries physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes.
• Keeps abreast of coding guidelines and reimbursement reporting guidelines and brings identified concerns to manager for resolution.
• Effectively assigns ICD-10-CM, modifiers, and HCPCS codes to outpatient records.
• Responsible in maintaining 95% or greater ICD-10-CM and/or HCPCS coding and consistently meet established productivity standards while keeping abstracting errors to a minimum.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines.
• Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
• Demonstrates commitment to caring for every member of our community by creating compassionate and personalized experiences.
• Models Memorial Hermann’s service standards by providing safe, caring, personalized and efficient experiences to patients and colleagues.

Certified Outpatient Hospital/Facility Coding Specialist

• managing a team that audits, reviews, and codes medical records for the purpose of reimbursement and compliance using ICD-9 and CPT codes
• Develops, implements, and monitors policies, procedures, and systems for proper coding and quality assurance
• Manages workloads, training, and problem resolution
• Oversees all facets of the daily operations and ensures compliance
• Develops and implements systems and processes to establish and maintain records for the operating unit
• Manages projects designed to improve billing practices and increase revenues
• Assists physicians and providers with questions and problems related to coding and billing
• Plans, organizes, and conducts individual and group provider in-service programs
• Conducts quality control studies and audits and implements solutions
• Trains staff on coding, documentation and billing regulations
• Participates in developing, implementing, and maintaining policies and objectives
• Hires, trains, coaches, counsels, and evaluates performance of direct reports

Manager, Medical Coding Analysis

• Responsible for reviewing and abstracting inpatient medical records
• Identifying and assigning accurate medical codes for diagnosis, procedures and services
• Ensures that all data elements required for federal or state reporting and billing are collected
• Typically reports to the Coding Manager
• Reviews medical record documentation to identify pertinent diagnosis/procedures
• Queries physicians when code assignments are not straightforward or documentation in the record is inadequate
• Effectively assigns ICD-10 codes and DRGs to inpatient records
• Responsible in maintaining 92% to 95% in ICD-10 and DRG assignment
• Ensures safe care to patients, staff and visitors
• Promotes individual professional growth and development

Senior Certified Inpatient Coding 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
• 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

• Provides critical assessment of the health record documentation to accurately identify pertinent primary and secondary diagnosis and procedures that require ICD-10-CM/PCS code and MS-DRG assignment for proper billing complex (Medicare, high dollars, long LOS and high CMI) inpatient records.
• Abstracts and compiles clinical data elements such as attending physician, surgeon, consultants, ED physician, birth weight, etc. according to THR guidelines.
• Queries the physician and takes initiative to collaborate with Clinical Documentation Specialist and other departments when documentation in the record is ambiguous, inadequate, unclear or incorrect for accurate coding and compliance.
• Demonstrates and maintains adequate productivity and quality metrics as outlined in job description.
• Demonstrates and maintains coding proficiency by staying abreast of coding guidelines as published in Coding Clinic.

Coder III – Inpatient

• Review provider documentation of diagnostic data from medical records to verify that all Medicare Advantage, Affordable Care Act (ACO) and Commercial risk adjustment documentation requirements are met, and to deliver education to providers on either an individual basis or in a group forum, as appropriate for all IPAs managed by the company.
• Review medical record information on both a retroactive and prospective basis to identify, assess, monitor, and document claims and encounter coding information as it pertains to Hierarchical Condition Categories (HCC).
• Perform code abstraction and/or coding quality audits of medical records to ensure ICD-10- CM codes are accurately assigned and supported by clinical documentation to ensure adherence with CMS Risk Adjustment guidelines.
• Interacts with physicians regarding coding, billing, documentation policies, procedures, and conflicting/ambiguous or non-specific documentation.
• Prepare and/or perform auditing analysis and provide feedback on noncompliance issues detected through auditing.
• Maintain current knowledge of coding regulations, compliance guidelines, and updates to the ICD-10 and HCC codes, Stay informed about changes in Medicare, Medicaid, and private payer requirements.
• Provides recommendations to management related to process improvements, root-cause analysis, and/or barrier resolution applicable to Risk Adjustment initiatives.
• Trains, mentors and supports new employees during the orientation process. Functions as a resource to existing staff for projects and daily work.
• Provides peer to peer guidance through informal discussion and overread assignments. Supports coder training and orientation as requested by manager.
• May assist or lead projects and/or higher work volume than Risk Adjustment Coding Specialist I.
• Other duties as assigned.

Risk Adjustment Coding Specialist II

• 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

• Process claims to appropriate primary, secondary, and/or tertiary insurance company according to insurance guidelines
• Perform follow-up on unpaid insurance accounts identified through aging reports
• Process appeals when appropriate
• Process refund requests
• Identify trends, and carrier issues relating to billing and reimbursements, report findings to leadership
• Maintain Privacy & Confidentiality of patient information and organizational operations
• Responsible for learning, understanding and following payer guidelines
• Reallocate misapplied payments and adjustments
• Work special assignments when needed

Medical Billing & Collections Specialist

Certified Coder – Practice Operations – Part-Time

• Maximize reimbursement and minimize denials by assuring that proper coding guidelines have been met.
• Work within the Providence footprint states: AK, MT, CA, OR, TX, NM, and WA.

Associate Coder

• Under general supervision, responsible for assisting with analyzing medical record documentation against billing documentation guidelines and educates departments and faculty on appropriately documenting the medical record for services provided to patients.
• Conducts quality reviews of coding activities to ensure documentation supports coding rules and coding selection in accordance with all coding and billing standards.
• Researches and resolves coding related denials as reported.
• Reviews and resolves services in charge review to identify coding issues/trends.
• Recommends changes to policies and procedures to improve professional fee coding and data management.
• Performs all aspects of daily work in a manner that contributes to and ensures an environment of strict confidentiality.
• Provides feedback to providers based on quality reviews to minimize errors.
• Develops and performs training regarding documentation, billing and coding to inform providers of changes/updates in guidelines or activities that prevent denials or increase revenue.
• Provides education regarding coding, billing and documentation to end users and ancillary staff as needed.
• Reports compliance issues detected through reviews and collaborates with Compliance to identify and implement corrective action plan to resolve issue.

Coding Education Consultant – UTHP Transplant Coders

• Support day-to-day billing operations and back-office revenue cycle workflows
• Submit and track medical claims across payer channels
• Work claim rejections, denials, and unpaid claims through to resolution
• Investigate payer issues and perform follow-up on claim status
• Support manual billing workflows and operational tasks required to keep accounts moving
• Maintain billing accuracy across documentation, coding inputs, and claim submission workflows
• Identify patterns in denials or billing failures and flag them to the broader RCM team
• Support onboarding-related billing setup tasks for new provider accounts
• Document work clearly and maintain organized records of claim actions and follow-ups
• Escalate complex reimbursement, payer, or workflow issues to client-facing RCM team members
• Help improve SOPs and contribute to scalable billing operations over time

Medical Billing Specialist

• Responsible for primary diagnosis and procedural coding for designated ambulatory and hospital outpatient settings
• Assign proper and accurate medical codes for diagnosis, procedures, and services performed in an outpatient setting
• Typically reports to the Coding Manager
• Reviews medical record documentation to identify pertinent diagnosis/procedures for code assignment
• Effectively assigns ICD-10-CM, modifiers, and HCPCS codes to outpatient records
• Maintains 95% or greater coding accuracy and meets established productivity standards
• Adheres to the Standards of Ethical Coding as set forth by AHIMA
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education

Certified Outpatient Hospital Coding Specialist

• Responsible for timely and compliant Private Duty billing, authorizations, and reimbursement for designated region
• Work directly with revenue cycle director, billing compliance coordinator, agencies, and intermediary to facilitate billing claims
• Obtain authorizations as needed
• Prepare, audit, and submit claims electronically for appropriate payment
• Follow up on outstanding claims and take appropriate action for timely payment
• Collect necessary information to prepare claims, coordinating with agencies when appropriate
• Bill and submit clean claims electronically and follow up with the Payer
• Process, collect, and manage account payments
• Monitor claims daily, report totals
• Research, correct, and re-submit rejected and denied claims
• Follow-up on corrections and report adjustments using revenue cycle management tool
• Monitor and maintain assigned accounts
• Review billing reports to maintain accurate AR balances
• Document follow-ups on claim outstanding balance until final resolution is reached
• Keep accurate and orderly records for all billing and accounts receivable activity
• Conduct pre-billing audits as assigned
• Proactive in identifying potential reimbursement issues while ensuring effective problem resolution
• Coordinate with the Agency and Billing Compliance Coordinator on relevant process issues impacting billing
• Report any billing issues that develop into trends to immediate supervisor
• Answer questions from patients, agency staff, and insurance companies
• Interpret and process Explanation of Benefits when needed
• Professionally make outbound calls while improving customer relations
• Maintain knowledge of current industry standards related to billing and cognizant of new regulations

Medical Billing Specialist, Cash Poster

• Responsible for revenue cycle functions including coding/edit charge review
• Accurate timely submission of insurance claims
• Failed claims/follow‐up resolutions
• Training and education on coding
• Conduct chart reviews on documentation and correct coding
• Ensures compliance with governmental and contractual obligations
• Clearing all coding edits generated by EMR/PM
• Process insurance payments and reconcile deposits
• Serve as an intermediary between healthcare providers, patients, and health insurance companies

Revenue Cycle and Coding Specialist

• Own high-impact medical billing and insurance cases end-to-end
• Assess whether procedure, diagnosis, and modifier codes on an EOB are consistent with service described
• Identify coding conflicts and escalate or dispute them with the appropriate party
• Advocate for users by pushing cases forward with persistence
• Communicate clearly with users, setting expectations and sharing progress

Healthcare Advocate, Medical Coding

• Ability to comprehend medical record documentation to accurately assign codes for both concurrent and discharged accounts across multiple specialties.
• Meets minimum requirements for production and quality monthly.
• Requires a working knowledge of code sequencing for grouper-related payers with attention to detail to avoid rework and waste with charge capture assessment component.
• Requires understanding and application of M.E.A.T. criteria (i.e., monitoring, evaluation, assessment, treatment) using ICD 10 CM transaction data set to capture diagnoses.
• Analyzes high-risk encounters for accurate and/or missing charges gaps prior to encounter completion (i.e., missing charges from anesthesia, surgery) when manual charge capture occurs.
• Understand complexity of billing requirements and incorporates payer specific trends into day-to-day reviews to reduce “take backs” associated with un-clear, or un-substantiated care rendered.
• Requires excellent coding knowledge of ICD 10 CM, CPT 4, and modifier application, with expectations to maintain certification (i.e., CCS, CPC, RHIT, or RHIA) and apply ICD 10 CM Coding Guidelines specific to both inpatient and outpatient encounters.
• Facilitate modifications to clinical documentation through query interaction to ensure that the information captured supports the level of service rendered, with attention towards chronic conditions, hierarchical condition categories (HCC), and risk adjustment factors (RAF).

Inpatient Coder

• Responsible for reviewing, auditing, and data entry of medical bills for multiple states and lines of business within both Worker’s Compensation and Commercial Health arenas.
• Responsible for auditing medical bills to ensure that they are appropriate and adhere to the State Fee Schedules, customer guidelines, and PPO discounts
• Analysis and review of 1 or more assigned states having fee schedules
• Utilize Fee Schedules, Online Documents, Client instructions, and other training material to properly review medical bills
• Review medical bills for compensability and relatedness to injury
• Reprice medical bills to Workers’ Compensation Fee Schedule and PPO Network
• Research usual and customary/fee schedule applications and system interface as appropriate
• Reviews specialized Medical Bills, which include hospital, surgery, and high-level physician bills
• Determine reimbursement outcomes by applying either Fee Schedule reduction, PPO reduction, Usual and Customary reduction, or Medicare reduction
• Communicates and defends to providers and clients the basis for the methodology used to accomplish the reduction of charges
• Analyzes and reviews high-level office visits, reports, and record reviews
• Interprets hospital review guidelines for both inpatient and outpatient claims
• Responsible for producing a final review for the recommendation of payment to the client
• Maintain productivity, as well as speed and level of accuracy, as determined by company standards.

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