Certified Medical Coder

SUMMARY/OBJECTIVES

The Certified Medical Coder is responsible for the timely, accurate, and compliant review, abstraction, and coding of professional healthcare services provided by Edgewater Health clinicians. This position ensures that medical documentation supports the assignment of appropriate ICD-10-CM, CPT, and HCPCS Level II codes to facilitate accurate reimbursement while maintaining compliance with federal and state regulations, payer requirements, and organizational policies.

The Certified Medical Coder works collaboratively with providers, clinical leadership, billing staff, and the Revenue Cycle Department to optimize documentation quality, improve coding accuracy, reduce claim denials, and maximize reimbursement. This position plays an integral role in supporting Edgewater Health's behavioral health, primary care, substance use treatment, and Federally Qualified Health Center (FQHC) billing operations.

ESSENTIAL DUTIES AND RESPONSIBILITIES

The essential functions include, but are not limited to, the following:

Medical Coding and Documentation

• Review medical records to accurately identify diagnoses, procedures, and services rendered by providers.
• Assign appropriate ICD-10-CM diagnosis codes, CPT procedure codes, and HCPCS Level II codes according to current coding guidelines.
• Ensure coding accurately reflects the documentation contained within the patient's medical record.
• Review documentation for medical necessity, completeness, specificity, and compliance with payer requirements.
• Identify incomplete, conflicting, or unclear documentation and communicate with providers for clarification when appropriate.
• Ensure all billable services are captured accurately to maximize reimbursement.
• Verify appropriate use of modifiers and coding edits.
• Perform coding for behavioral health, primary care, substance use treatment, crisis services, and other clinical specialties supported by Edgewater Health.
• Assist with charge capture review to ensure all services performed are appropriately billed.

Compliance and Quality Assurance

• Maintain compliance with:
  • HIPAA Privacy and Security Rules
  • CMS regulations
  • Medicare and Medicaid billing requirements
  • FQHC billing regulations
  • Indiana Medicaid policies
  • Commercial payer guidelines
  • National Correct Coding Initiative (NCCI) edits
  • Official ICD-10-CM, CPT, and HCPCS coding guidelines
• Adhere to the American Academy of Professional Coders (AAPC) Code of Ethics and the American Health Information Management Association (AHIMA) Standards of Ethical Coding.
• Participate in internal coding audits and external compliance reviews.
• Assist in correcting coding errors identified during audits.
• Maintain coding accuracy standards of at least 95% while meeting productivity expectations.
• Stay current with annual coding updates, regulatory changes, and payer requirements.

Revenue Cycle Support

• Collaborate with billing staff to resolve coding-related claim denials.
• Assist with appeals by providing coding support and documentation review.
• Monitor coding-related denial trends and recommend corrective actions.
• Work with providers and clinical leadership to improve documentation practices that support reimbursement.
• Assist with implementation of coding-related process improvements.

Education and Training

• Educate providers and clinical staff regarding coding requirements and documentation standards.
• Participate in provider education related to coding updates and reimbursement changes.
• Assist with onboarding and training of new coding staff as assigned.
• Maintain active coding certification through continuing education requirements.

Reporting

• Maintain coding productivity and quality reports.
• Identify documentation trends impacting reimbursement.
• Provide recommendations to improve documentation quality and coding compliance.
• Participate in quality improvement initiatives related to revenue cycle performance.

Other Duties

• Demonstrate excellent customer service in all interactions.
• Maintain strict confidentiality of patient and organizational information.
• Participate in departmental meetings and organizational training.
• Perform other duties as assigned by the Revenue Cycle Manager.

REQUIRED COMPETENCIES-KSAS

Knowledge

• ICD-10-CM diagnosis coding
• CPT procedural coding
• HCPCS Level II coding
• Medical terminology
• Anatomy and physiology
• Pharmacology fundamentals
• Behavioral health coding
• Primary care coding
• FQHC billing methodology
• Medicare and Medicaid regulations
• Commercial payer reimbursement guidelines
• National Correct Coding Initiative (NCCI)
• Medical necessity requirements
• HIPAA regulations
• Electronic Health Records (EHR)

Skills

• Exceptional attention to detail
• Strong analytical skills
• Medical record review
• Critical thinking
• Problem-solving
• Time management
• Organizational skills
• Written and verbal communication
• Microsoft Office Suite proficiency
• Electronic Health Record navigation

Abilities

• Interpret complex medical documentation.
• Maintain high coding accuracy and productivity.
• Prioritize multiple assignments.
• Meet strict deadlines.
• Communicate professionally with providers and staff.
• Work independently with minimal supervision.
• Maintain confidentiality of protected health information.