
Clinical Documentation Specialist
2 weeks ago
Job Title:
About the Role:
Key Responsibilities:
- Review medical documentation and assign appropriate codes using ICD-10-CM, CPT, and HCPCS guidelines.
- Conduct risk adjustment and HCC coding to accurately identify chronic conditions.
- Perform chart audits to evaluate documentation and ensure it supports code assignments.
- Ensure coded data comply with payer and regulatory guidelines.
- Resolve queries with providers when medical records are unclear or missing details.
- Maintain productivity and accuracy targets.
- Stay updated on coding changes, industry regulations, and certification requirements.
- Participate in training and process improvement initiatives.
- Assist in denial management, claims adjudication, and revenue leakage identification.
- Maintain patient confidentiality and security.
Required Qualifications:
- Certification: CPC and/or CRC from recognized bodies.
- Graduate degree preferably in Life Sciences.
- Typically 1-3 years of coding experience in U.S. healthcare.
- Strong knowledge of medical terminology and anatomy.
- Proficiency in ICD-10-CM, CPT, and HCPCS.
- Good analytical skills and attention to detail.
- Effective communication skills.
- Computer skills: EHR, EMR tools, MS Office, and coding software.
- Prior experience in facility setting coding.
- Ability to mentor junior coders.
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