Coding Analyst

RESPONSIBILITIES

• Ability to analyze and interpret medical records and codes for appropriate diagnosis and procedures as it relates to coding
• Ensure accurate coding by following established principles and guidelines
• Review clinical documentation and diagnostic results as appropriate to extract data and apply appropriate ICD-9 codes for billing, internal and external reporting, research and regulatory compliance
• Pairs CPT/ICD9 codes for accurate billing and maximum reimbursement
• Participates in educational training to stay current with coding requirements as set by Department and/or Company.

QUALIFICATIONS

• 3-5 years’ experience in medical coding, hospital setting preferred
• Certified RHIA, RHIT, and/or CCS is preferred
• Proven ability to learn new software programs
• Possess extensive knowledge of medical terminology, the human disease process, anatomy and physiology
• Exhibit time management, organizational, verbal and written communication skills
• Maintain strong skills in diplomacy, professionalism and trustworthiness

Essential Key Responsibilities

• Analyze Denials : Review remittance advices (ERAs) and explanations of benefits (EOBs) to identify the specific root causes of coding-related denials.
• Audit Documentation : Evaluate electronic health records (EHR) against provider documentation to verify coding accuracy for CPT, ICD-10-CM/PCS, and HCPCS Level II systems.
• Correct and Resubmit : Modify erroneous claims using proper modifiers (e.g., -25, -59), corrected diagnosis linking, or updated procedure codes for immediate resubmission.
• Cross-Track Auditing : Identify root causes of denials for both hospital facility claims (DRG, APC, status changes) and professional fee claims (E&M levels, teaching physician rules).
• Track Trends : Monitor systemic denial patterns by specific payers or departments and report findings to management to prevent future revenue leakage.
• Multi-EHR Navigation : Seamlessly switch workflows between diverse Electronic Health Record (EHR) platforms and clearinghouses to research claim histories.
• Complex Appeal Writing : Draft evidence-based appeal letters addressing clinical medical necessity, bundling issues, and complex NCCI edits.
• Claim Correction : Apply appropriate CPT, ICD-10-CM/PCS, HCPCS Level II codes, and complex modifiers (e.g., -25, -59, -78, -GC) to resubmit optimized claims.
• Virtual Provider Inquiry : Conduct electronic and video-based queries with clinicians to clarify ambiguous documentation across various departments.
• Query Providers : When appropriate, collaborate with physicians and clinical staff to clarify ambiguous documentation and secure missing charts needed to overturn claims.
• Remote Productivity : Meet strict daily quotas for claim reviews and appeal submissions while maintaining a minimum 95% coding accuracy rate.
• Payer Policy Tracking : Stay updated on evolving CMS regulations, monitor evolving LCDs, NCDs, and private payer reimbursement policies affecting both institutional and professional claims and report findings to management to prevent future revenue leakage.
• Identify Denial Trends : Track recurring denial patterns by payer, provider, or specialty to pinpoint systemic workflow issues.
• Educate Clinical Staff : Provide feedback to physicians and documentation specialists regarding gaps in medical charts that lead to preventable denials.
• Check Modifier Usage : Investigate whether modifiers were applied incorrectly, omitted, or if they lack supporting documentation in the medical record.
• Assess Medical Necessity : Evaluate if the documented diagnosis codes adequately justify the necessity of the performed procedures according to payer policies.

Required Qualifications & Skills

• Certification : Dual credentials preferred, or at least one active core credential from AAPC (CPC, COC) or AHIMA (CCS, CCS-P, RHIT, RHIA).
• Experience : Minimum 3–5 years of medical coding experience, with at least 2 years explicitly handling both inpatient/outpatient facility and professional fee denials .
• EHR Versatility : Proven track record of high adaptability using multiple EHR systems (e.g., Epic, Cerner, Meditech, eClinicalWorks, SFM) and encoder tools (e.g., 3M).
• Remote Setup : Must possess a private, HIPAA-compliant home office with high-speed internet access.
• Self-Management : Strong time-management skills to work independently without direct, face-to-face supervision.

Performance Metrics (KPIs) <