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As the Certified Coder for SDCHC, the position will be responsible for ensuring accurate, complete, and compliant medical coding practices across the organization in compliance with HRSA Section 330, Medi-Cal, and Medicare requirements.

The Certified Coder bridges clinical documentation and billing by reviewing provider-documented encounters, verifying and assigning ICD-10-CM, CPT, and HCPCS codes, and supporting providers through coding education and documentation feedback. Working closely with the CFO and revenue cycle staff, this role serves as the organization's primary coding resource, protecting PPS/wraparound reimbursement, UDS reporting accuracy, HEDIS and quality measure capture, and audit readiness consistent with HRSA Health Center Program requirements and Section 330 grant compliance.

The responsibilities of coding compliance include the development, implementation, education, data collection, and analysis of coding accuracy across the organization. The position includes detection, monitoring, prevention, reporting, and correction of coding errors, documentation gaps, and potential compliance risk. It also includes support for payer audits, HRSA site visits, and OIG-related inquiries. The person responsible for coding compliance cultivates a culture of accuracy and accountability through provider education, clear guidance, and open communication.

Essential Duties and Responsibilities:

Primary Functions:

Coding Review & Verification

1. Reviews, verifies and updates ICD-10-CM, CPT, and HCPCS Level II codes assigned to provider encounters prior to claim submission, ensuring alignment with documentation, medical necessity, and FQHC-specific billing rules (e.g., PPS encounter definitions, qualifying visit codes, G0466–G0470 series) with a 48-hour claims submission deadline from visit date.
2. Conducts retrospective and concurrent coding audits, including 100% review of high-risk encounter types (new patient E/M, behavioral health, care coordination, quality-incentive-linked visits) and periodic sampling across all providers.
3. Tracks and trends coding error patterns organization-wide and reports findings to the CFO and relevant department leadership

Provider Support & Education (Primary Responsibility)

1. Identifies documentation gaps and communicates individualized, constructive feedback to providers through a structured Clinical Documentation Improvement (CDI) feedback loop.
2. Serves as the primary coding resource for clinical and billing staff, answering day-to-day coding questions and escalating ambiguous scenarios to the CFO.
3. Delivers periodic (at minimum annual) coding and documentation training for providers and clinical staff, tailored to FQHC-specific requirements, payer updates, and audit findings.
4. Maintains and updates internal coding guidelines, quick-reference tools, and EHR templates/order sets in collaboration with clinical informatics and revenue cycle staff.

Regulatory & Policy Monitoring

1. Monitors and interprets changes in Medi-Cal, Medicare, and state-only billing policy affecting FQHC coding (e.g., AB 116 state-only services transition, scope-of-service changes, sliding fee scale interactions) and translates them into actionable coding guidance.
2. Supports HEDIS, UDS, GPRA, and grant-specific quality reporting by ensuring diagnosis and service codes accurately reflect care delivered, including chronic condition and risk-adjustment-relevant capture.
3. Keeps up to date with new and revised state and federal coding and billing regulations. Reviews and evaluates related policies and procedures and recommends revisions as needed.

Audit & Compliance Support

1. Assists with responses to payer audits, HRSA Operational Site Visits (OSV), and OIG-related inquiries by compiling documentation and coding evidence.
2. Maintains strict confidentiality of patient health information in accordance with HIPAA and 42 CFR Part 2 where applicable.
3. Analyzes coding audit reports and advisories that identify compliance risk and billing accuracy patterns and trends for leadership.

Support to the CFO

1. Provides regular updates to the CFO regarding coding accuracy trends, provider education needs, and audit findings.
2. Brings provider and clinical staff feedback forward to inform coding policy decisions and continuous improvement.
3. Performs other duties as assigned in support of compliance and revenue cycle operations

Qualifications:

Minimum Qualifications:

1. Active coding certification required: CPC (Certified Professional Coder, AAPC) or CCS (Certified Coding Specialist, AHIMA); CRC (Certified Risk Adjustment Coder) a plus.
2. Minimum two (2) to three (3) years of medical coding experience required.
3. Experience in a Federally Qualified Health Center (FQHC), community health center, or safety-net setting strongly preferred.
4. Demonstrated experience with HRSA Health Center Program compliance, UDS reporting, PPS reimbursement methodology, and/or Medi-Cal/Medicare billing rules preferred.
5. Familiarity with 340B, HEDIS, GPRA, or coding audit standards a plus.

Knowledge, Skills and Abilities:

1. Strong organizational, problem-solving, and communication skills.
2. Ability to manage multiple priorities in a fast-paced environment.
3. Coding accuracy review and documentation improvement strategies.
4. Working knowledge of FQHC billing, reimbursement, and documentation requirements.
5. Attention to detail and accuracy.
6. Workflow optimization and process improvement.
7. Collaboration and provider relationship-building.
8. Time management and prioritization.
9. Adaptability in a growing program environment.
10. Trustworthy, reliable, and ongoing communication with the CFO on coding discrepancies.
11. Adapts positive and team-oriented culture; assists with team dynamics and team building.

Physical and Mental Requirements:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job with or without accommodation.

1. Able to lift/move up to 15 pounds, move from place to place.
2. Able to sit at a desk and work on a computer for prolonged periods.
3. Able to stand, bend and reach for prolonged periods.
4. Ability to do math, organize and prioritize workload, work effectively and efficiently under stress.
5. Ability to multitask, understand, and follow instructions.
6. Ability to proficiently read, write, speak, and understand English.

Customer Service:

1. Actively supports, promotes, and works to fulfill the Mission, Vision, and core values of SDCHC.
2. Provides excellent internal and external customer service.
3. Demonstrates SDCHC's Standards of Customer Service Behavior: Compassion, Attitude, Communication, Appearance, Sense of Ownership, and Teamwork.
4. Participate in on-going customer service training, Motivational Training and other training as assigned
5. In every action, seeks to promote SDCHC as a top service organization.

Quality Management:

1. Contribute to the success of the organization by participating in quality improvement activities.
2. Comply with all SDCHC policies and procedures and proactively participates in the implementation of new initiatives.
3. Participate and ensure continuous quality improvement processes as directed by compliance leadership.

Safety:

1. Ensures regulatory compliance and adherence with policies and procedures related to safe work practices.
2. Participate in infection prevention through appropriate use of infection control measures as applicable.
3. Ensure compliance with regulatory requirements for maintaining physical spaces, equipment, and supplies.
4. Use all appropriate equipment and/or tools to ensure workplace safety.
5. Immediately reports unsafe working conditions.

Privacy/Compliance:

1. Maintains privacy and security of all patients, employees, and volunteer information and access to such information. Such information is accessed on a need-to-know basis for business purposes only.
2. Complies with all regulations regarding corporate integrity and security obligations. Reports on unethical, fraudulent, or unlawful behavior or activity.
3. Upholds strict ethical standards.

Flexibility: Available for standard business hours; occasional flexibility required to meet audit response deadlines, training schedules, or reporting cycles.

Disclaimer

Nothing in this job description restricts management's right to assign or reassign duties and responsibilities to this job at any time. This description reflects management's assignment of essential functions; it does not proscribe or restrict the tasks that may be assigned. This job description is subject to change at any time.

Preference is given to qualified American Indian/Alaskan Natives in accordance with the American Indian Preference Act (Title 25, U.S. Code Section 472, 473 and 473a). In other than the above, the San Diego Community Health Center, is an equal opportunity employer.

Acknowledgement

San Diego American Community Health Center is an Equal Opportunity Employer. We encourage applications from all individuals regardless of race, religion, color, sex, pregnancy, national origin, sexual orientation, gender identity, gender expression, ancestry, age, marital status, physical or mental disability or any other protected class, political affiliation or belief.