Coding Compliance Specialist researches and develops the pre-certification insurance policy standards and criteria used by case management and utilization reviewers that will ensure that requested medical services are appropriate and medically necessary. Collaborates with medical professionals to resolve questions about policy development and standards. Being a Coding Compliance Specialist assigns correct ICD, CPT, or other coding assignments for medical procedures that support policy standards in claims systems. Provides expertise and solutions to users regarding the appropriate coding for claims. Additionally, Coding Compliance Specialist has broad knowledge of medical coding systems. May require an associate degree in healthcare administration, a related field, or equivalent. Requires AAPC Certified Professional Coder (CPC). May alternatively require Certified Coding Specialist (CCS) certification. Typically reports to a manager. The Coding Compliance Specialist occasionally directed in several aspects of the work. Gaining exposure to some of the complex tasks within the job function. To be a Coding Compliance Specialist typically requires 2 -4 years of related experience. (Copyright 2024 Salary.com)
Job Summary: To perform diversified coding of clinic encounters to accurately reflect the services provided in the clinic setting, using ICD-10-CM and CPT coding conventions including application of Evaluation & Management guidelines, and appropriate modifier usage. Performs abstract coding functions for each encounter coded by reviewing to validate the documentation supports the codes submitted on claims. Maintain a thorough understanding of anatomy and physiology, medical terminology, disease processes, and surgical techniques through participation in continuing education to effectively apply ICD-10-CM/CPT coding guidelines to professional fee billed encounters.
Qualifications: Education and formal training: High school graduate/diploma required. Training in ICD-10 and CPT coding conventions. Applicants must be eligible for a qualifying certification but has not taken an exam, or has taken and passed an exam but has less than 2 years of experience. Qualifying certifications for this position include those offered by AAPC or AHIMA including CPC, RHIA, RHIT, CCS, CCS-P or CPC-A. Individuals hired in this position will be moved to a Coding Specialist II position after obtaining 2 years’ experience. Excellent verbal and written communication skills. Must be able to maintain the highest level of confidentiality of sensitive information. Must have knowledge of Medicare, Medicaid and other payer requirements related to coding and billing claims for services rendered. Excellent verbal and written communication skills. . Must be able to maintain the highest level of confidentiality of sensitive information. Familiar with coding software preferred.
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