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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.

MINIMUM QUALIFICATIONS

• Education: High School Diploma or GED required.
  • Certified Professional Coder (CPC) credential through the American Academy of Professional Coders (AAPC) required.
• Experience:
  • Minimum of two (2) years of professional medical coding experience.
  • Working knowledge of: ICD-10-CM; CPT; HCPCS Level II; Medical terminology, Anatomy and physiology
  • Experience with Electronic Health Records (EHR)
  • Proficiency with Microsoft Office applications.
  • Excellent written and verbal communication skills.
  • Strong organizational and time management abilities.

PREFERRED QUALIFICATIONS

• Associate’s degree in health information management, Medical Coding, Healthcare Administration, or related field.
• Three (3) or more years of professional coding experience.
• Certified Professional Medical Auditor (CPMA), Certified Outpatient Coder (COC), Certified Coding Specialist (CCS), or Certified Inpatient/Outpatient Coder preferred.
• Experience coding for:
  • Federally Qualified Health Centers (FQHCs)
  • Certified Community Behavioral Health Clinics (CCBHCs)
  • Behavioral health
  • Primary care
  • Substance use treatment programs
• Knowledge of Indiana Medicaid behavioral health billing requirements.
• Experience with Athenahealth or similar EHR and practice management systems.

SUPERVISORY

• Reports To: Revenue Cycle Director
• Supervise: This position does not have direct supervisory responsibilities. The Certified Medical Coder may assist providers, clinical staff, and Revenue Cycle personnel regarding coding requirements and documentation improvement.

CORE COMPENTENCIES

Employees ae expected to demonstrate the following organizational competencies:

• Integrity
• Customer Service
• Accountability
• Communication
• Teamwork
• Continuous Learning
• Quality Focus
• Adaptability
• Professionalism

PERFORMANCE EXPECTATIONS

Performance will be evaluated based on, but not limited to:

• Achieving a coding accuracy rate of 95% or greater.
• Meeting established coding productivity benchmarks.
• Timely completion of assigned coding work.
• Reduction in coding-related claim denials.
• Compliance with payer and regulatory requirements.
• Accurate assignment of ICD-10-CM, CPT, HCPCS, and modifier codes.
• Quality of provider documentation improvement efforts.
• Participation in coding education and quality initiatives.
• Professionalism and teamwork.
• Attendance and dependability.
• Maintenance of active coding certification and continuing education requirements.

WORK ENVIRONMENT AND PHYSICAL REQUIREMENTS

This position is primarily performed in a professional office environment.

The employee is regularly required to:

• Sit for extended periods.
• Use a computer, keyboard and telephone throughout the workday.
• Perform repetitive hand and wrist movements.
• Read printed materials and computer screens.
• Communicate verbally and in writing.
• Occasionally stand, walk, bend, reach, or lift office materials weighing up to 20 pounds.
• Travel occasionally between Edgewater Health locations for meetings or training.

Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions of this position.

WORKING CONDITIONS:

• Standard business hours with occasional extended hours based on operational needs.
• Fast-paced healthcare environment with multiple priorities and deadlines.
• Frequent interaction with patients, providers, insurance companies, government agencies, and staff.
• Exposure to confidential patient, employee, financial, and organizational information requiring strict adherence to HIPAA and confidentiality standards.
• Must maintain professionalism while managing competing priorities and responding to changing payer regulations and organizational needs.
• Participation in departmental meetings, organizational training, quality improvement initiatives, and continuing education is expected.