We are seeking an experienced Medical Documentation Coding Specialist – Family Medicine to support accurate, timely, and compliant clinical documentation and charge capture. The ideal candidate will have at least 3 years of experience in family medicine, medical documentation, coding, clinical chart review, or a related healthcare setting.
Key Responsibilities
AI-Assisted Clinical Documentation
- Review AI-generated clinical documentation in AdvancedMD after the provider saves the patient encounter.
- Edit, organize, and complete SOAP notes to ensure accuracy, completeness, clarity, and clinical appropriateness.
- Complete and finalize the Assessment & Plan (A&P) based on the provider's documented recommendations and treatment plan.
- Ensure pertinent patient history, physical examination findings, diagnoses, assessments, and treatment plans are accurately documented.
- Verify documentation for completeness and accuracy before routing the chart to the provider for review and sign-off.
- Identify missing, inconsistent, or unclear documentation and follow established procedures for clarification when necessary.
Clinical Documentation & EHR Management
- Complete the physical examination section using the provider's documented findings.
- Enter and document laboratory, imaging, and other diagnostic study results reviewed during the encounter.
- Document all Point-of-Care (POC) testing performed in the office, including test results.
- Enter CURES review dates and other required controlled-substance monitoring information, as applicable.
- Ensure clinical documentation is accurately entered, properly organized, and appropriately formatted within AdvancedMD.
- Maintain consistency and accuracy across the patient's medical record.
- Follow established documentation workflows and quality standards.
Charge Capture & Coding Support
- Complete charge slips for each patient encounter.
- Accurately document and capture:
- ICD-10-CM diagnoses
- CPT procedure codes
- Appropriate office visit/E&M level
- Point-of-Care testing
- Injections and vaccines
- Other billable services provided during the encounter
- Ensure all services rendered are supported by appropriate clinical documentation.
- Review encounters for potential missing charges or documentation that may affect accurate reimbursement.
- Apply current coding guidelines and organizational policies when performing documentation and coding-related duties.
Compliance & Confidentiality
- Maintain strict compliance with HIPAA and applicable healthcare privacy and security regulations.
- Protect the confidentiality and security of all Protected Health Information (PHI).
- Maintain accurate and complete medical records in accordance with organizational policies and applicable regulatory requirements.
- Follow clinic standards for documentation, coding, record retention, and medical record integrity.
- Maintain professional discretion when handling sensitive patient and clinical information.
Qualifications
- Minimum 3 years of experience in medical documentation, clinical documentation, medical coding, chart review, or a related healthcare role.
- Experience working in Family Medicine or a primary care setting strongly preferred.
- Strong knowledge of medical terminology and clinical documentation.
- Working knowledge of ICD-10-CM and CPT coding.
- Familiarity with Evaluation and Management (E/M) coding and charge capture.
- Experience documenting or reviewing laboratory, imaging, POC testing, injections, vaccines, and other outpatient services.
- Experience with an EHR system; AdvancedMD experience is highly preferred.
- Understanding of HIPAA and medical record confidentiality requirements.
- Excellent attention to detail and ability to identify documentation discrepancies.
- Strong written and verbal communication skills.
- Ability to work independently, manage multiple encounters, and meet documentation deadlines.
- Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent credential.
- Experience with AI-assisted clinical documentation platforms.
- Experience with CURES/controlled-substance monitoring documentation.
- Familiarity with outpatient family medicine coding and billing workflows.
- Experience working with U.S.-based healthcare providers and medical practices.
- Amenable to work during US hours
- Must be willing to undergo a background check as part of the hiring process.
Perks
- Permanent Work From Home
- Leave Credits
- Monetary Allowance
- Annual Bonus
- Weekly Paychecks
- Fixed Weekends Off
- Thriving Company Culture with Complete Autonomy
- Exclusive Specialized Training Programs
- Unlock Your Potential with a Highly Competitive Salary
Who are we?
BizForce is one of the fastest-growing global outsourcing companies in the world, founded in the US in Tucson, Arizona and is now operational in PH! Our Commitment to delivering high-quality results for our clients and the only way to do that is ensuring a rewarding, respectful and productive experience for our employees. We hold the same values for both our customers and our employees.