Job Description:
• Review patient records to ensure documentation supports appropriate billing and coding; including diagnoses, services rendered, and medical necessity.
• Identify documentation gaps that may impact reimbursement, compliance, or patient care. Work with providers to resolve them.
• Assist providers in understanding documentation requirements related to coding Standards (e.g., CPT, ICD-10) and payer guidelines.
• Conduct routine chart audits to validate accuracy and alignment between clinical documentation and billing data.
• Collaborate with the billing department to ensure clean claims and reduce denials or rework.
• Provide real-time or retrospective feedback to clinicians to improve documentation practices
• Track trends in documentation errors, coding issues, and claim denials. Report findings on leadership.
• Support compliance with HIPAA, state regulations, and payer-specific requirements.
• Develop training materials and provide education to medical and clinical staff on best practices for documentation, billing, and coding
• Assist in the management of organizational projects as needed.
• Assists in evaluating and standardizing operations, policies, and procedures.
• Assist with training and education of staff upon request
Requirements:
• Associate or Bachelor's degree in health information management, Healthcare Administration, Nursing, or related field preferred
• High School Diploma/GED Required
• Certified Professional Coder Certification preferred
• 2+ years of experience in healthcare data validation, clinical documentation improvement (CDI), medical billing/coding, or chart auditing.
• NextGen software experience preferred.
• High attention to detail and strong organization skills are essential.
• Experience using electronic health care records.
• Excellent interpersonal skills, capable of confidently and effectively presenting and speaking.
• Able to work independently, collaboratively, and proactively to accomplish work goals.
• Excellent computer skills.
• Proficient in basic data analysis, reporting to include spreadsheets, charts, and diagrams.
• Proficient in Microsoft Office Suite and managing projects through a full cycle process.
• Must have a Fingerprint clearance card or be eligible to obtain one.
Benefits:
• Generous PTO
• 10 paid holidays per year
• Medical plans (4 choices)
• Dental plans (2 choices)
• Vision plans (2 choices)
• 403(b) retirement plan
• Retirement Allowance
• Company paid Life/AD&D and Long-Term Disability
• Voluntary additional Life and Short-Term Disability
• Tuition Reimbursement
• Licensure Reimbursement
• Elder Care assistance
• Pet Insurance and much more!