Coding Specialist

Essential Duties and Responsibilities

• Review patient medical records, clinical notes, assessments, treatment plans, and other supporting documentation to identify diagnoses, treatments, and procedures requiring coding.
• Assign accurate ICD-10-CM and applicable procedural codes based on provider documentation and established coding guidelines.
• Apply current ICD-10 coding guidelines specific to mental health, behavioral health, substance use, and psychiatric hospitals/facilities.
• Ensure codes accurately reflect the patient's documented diagnoses, services provided, and level of care.
• Review documentation for completeness, consistency, and accuracy prior to coding and billing.
• Identify missing, unclear, conflicting, or ambiguous documentation and communicate with physicians, nurses, and other clinical staff to obtain clarification when appropriate.
• Maintain a high level of accuracy and attention to detail when reviewing medical records to minimize billing, financial, compliance, and legal risks.
• Ensure coding practices comply with applicable federal and state regulations, HIPAA requirements, payer requirements, and organizational policies.
• Maintain confidentiality and security of protected health information (PHI) at all times.
• Collaborate with clinical, billing, utilization review, and administrative departments to resolve coding and documentation issues.
• Stay current with changes to ICD-10 guidelines, coding requirements, payer regulations, and applicable behavioral health and substance use treatment standards.
• Identify potential documentation and coding discrepancies and bring concerns to appropriate leadership for resolution.
• Utilize electronic health record (EHR) systems, medical billing software, and other technology necessary to perform coding responsibilities.
• Assist with audits, quality assurance reviews, and compliance activities related to medical records and coding.
• Maintain organized and accurate coding records and documentation.
• Perform other duties and responsibilities as assigned by management.

Required Qualifications & Skills

• Strong grasp of medical terminology
• Must have Credentials like CPC (Certified Professional Coder) or CCS (Certified Coding Specialist).
• Pays Attention to details, and have high accuracy in reading medical records to prevent financial or legal errors.
• Proficiency with electronic health record (EHR) and medical billing software.

Preferred Qualifications

• Experience coding in a psychiatric hospital, behavioral health facility, substance use treatment center, or similar healthcare setting.
• Experience with behavioral health and substance use disorder coding.
• Experience working with insurance claims, reimbursement, billing, or utilization review.
• Knowledge of Medicare, Medicaid, commercial insurance, and other applicable payer requirements.
• Experience participating in coding audits or compliance reviews.

Core Competencies

• Accuracy and attention to detail
• Medical terminology and coding knowledge
• Knowledge of behavioral health and substance use documentation
• Confidentiality and professionalism
• Effective communication
• Critical thinking and problem-solving
• Organization and time management
• Regulatory and compliance awareness
• Teamwork and collaboration