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A Coder I performs post claim reviews of denied and retracted claims to identify coding-related issues, determine appropriate corrections, and provide feedback to providers, office staff, billing staff, and other departments. This position supports accurate coding and appropriate reimbursement by reviewing medical record documentation, researching coding guidelines, identifying trends in coding-related denials, and providing education and recommendations to improve coding accuracy and documentation. The Coder I works collaboratively with the Billing team, site staff, providers, and other departments to resolve coding-related issues and support successful claim resolution. 

Major Duties and Responsibilities 

• Maintains working knowledge of current CPT, HCPCS, ICD-10-CM, medical terminology, and applicable coding guidelines and payer requirements. 

• Reviews denied and retracted claims to identify coding, documentation, modifier, diagnosis, or other claim-related issues contributing to the denial or retraction. 

• Reviews medical record documentation as needed to determine whether the original coding was supported and whether a coding correction is appropriate. 

• Determines appropriate coding corrections based on documentation and applicable coding guidelines. 

• Provides recommendations regarding whether a denial or retraction should be corrected, appealed, or otherwise addressed. 

• Provides coding feedback and education to providers, site staff, billing staff, and other departments based on identified coding issues and denial trends. 

• Assists with the preparation and submission of appeals for coding-related denials and retractions, including identifying appropriate supporting documentation and coding rationale. 

• Collaborates with the billing team to resolve coding-related claim issues and support appropriate reimbursement. 

• Works with providers and site staff to improve documentation when documentation deficiencies contribute to coding-related denials. 

• Participates in coding-related denial discussions and meetings and communicates trends, findings, and recommendations. 

• Identifies recurring coding and documentation issues and communicates opportunities for education, process improvement, and denial prevention. 

• Researches payer-specific coding requirements and provides guidance regarding coding-related claim issues. 

• Communicates coding decisions and recommendations clearly and professionally to providers, site staff, billing staff, and other departments. 

• Escalates complex or unusual coding questions to the appropriate coding resource or leadership when additional guidance is needed. 

• Supports consistent application of coding guidelines and organizational coding processes across TPMG locations and departments. 

• Maintains confidentiality of patient and organizational information and follows HIPAA requirements. 

• Performs other duties as assigned.  

Knowledge, Skills and Abilities 

• Knowledge of CPT, HCPCS, ICD-10-CM, and applicable coding guidelines. 

• Knowledge of medical terminology, anatomy, physiology, and common medical procedures and diagnoses. 

• Knowledge of the relationship between medical record documentation, coding, claims, and reimbursement. 

• Understanding of common causes of coding-related claim denials and retractions. 

• Ability to review medical records and claims to identify coding discrepancies and documentation issues. 

• Ability to interpret coding guidelines and apply them appropriately to individual claims. 

• Ability to research and resolve coding questions using appropriate coding resources. 

• Ability to provide constructive coding feedback and education to providers, site staff, billing staff, and other departments. 

• Strong analytical and problem-solving skills. 

• Ability to examine documentation and claims for accuracy, completeness, and consistency. 

• Ability to prioritize and manage multiple claims, reviews, and follow-up activities. 

• Ability to communicate coding concepts clearly in both verbal and written formats. 

• Strong attention to detail and organizational skills. 

• Ability to work independently while also collaborating effectively with the billing team and other departments. 

• Ability to maintain confidentiality and handle protected health information appropriately. 

• Experience with ECW and Encoder Pro is a plus.  

Education / Training / Requirements 

• High School diploma/GED. 

• Up to 2 years related experience/training. 

• Up to 2 years in the medical billing field, with coding experience. 

• Possess and maintain active CPC-A, CPC, CCS, COC, CCS-P, or CCA certification required. 

Physical Demands 

• Ability to lift or move equipment. 

• Ability to stand and walk for limited periods of time. 

• Ability to sit for extended periods of time. 

• Ability to enter data into a computer via a keyboard. 

• Ability to occasionally reach, bend, stoop and lift up to 30 lbs. * 

• Ability to grasp and hold up to 30 lbs.* 

• Ability to occasionally squat and lean over. 

• Ability to hear normal voice level communications in person or through the telephone. 

• Ability to speak clearly and understandably. 

• Ability to see and understand data on a computer screen. 

Success Factors 

• Alignment with Company Mission and Core Values 

• Excellent Time Management/Organized 

• Open Communication/Positive 

• Goal Driven 

• Excellent Customer Service 

• Juggles Multiple Priorities 

• Accuracy and Attention to Detail 

• Accomplished in word processing and worksheet utilization