Clinical Coding & Documentation Specialist

University of North Texas - Denton; Fort Worth (TX); On-site; USD 65,000 - 90,000; Full time

Job summary

The Coding & Documentation Specialist at University of North Texas - Denton will review clinical documentation to ensure accurate coding and compliant submissions. You will work with clinicians and Billing to strengthen charge capture and reduce denials.

Responsibilities include auditing charts, ensuring CPT/HCPCS/ICD-10-CM alignment, and guiding teams on documentation improvements to optimize reimbursement, while maintaining HIPAA compliance and data confidentiality.

Qualifications

• Bachelor's degree or equivalent combination of education and experience.
• Strong knowledge of ICD-10-CM, CPT, HCPCS and modifiers.
• Understanding of Medicare, Medicaid and commercial payer billing requirements.
• Ability to interpret clinical documentation and determine supported codes.
• Proficient in maintaining confidentiality and HIPAA compliance.

Responsibilities

• Review clinical documentation and coding for accuracy, completeness, medical necessity, and compliance with coding and payer guidelines.
• Ensure CPT, HCPCS, ICD-10-CM, modifiers, and charges are supported by the medical record.
• Identify and resolve missing documentation, signatures, diagnoses, charges, and other issues delaying billing.
• Collaborate with clinicians to resolve documentation and coding concerns and provide ongoing education.
• Perform chart reviews and coding audits to identify trends, risks, and opportunities for improvement.
• Monitor pending and unbilled charges and follow up to support timely claim submission.
• Research and resolve coding-related claim edits and denials with Billing.
• Identify root causes of coding/documentation issues and recommend process improvements.
• Support accurate capture of quality measures (HEDIS, CMS Star) and payer incentive programs.
• Stay current on CPT, HCPCS, ICD-10-CM, CMS and payer requirements.
• Participate in Revenue Cycle, compliance, and clinician education initiatives.
• Maintain confidentiality and comply with HIPAA and coding standards.

Skills

ICD-10-CM knowledge

CPT knowledge

HCPCS knowledge

Modifier guidelines

EM coding knowledge

Medicare/Medicaid billing

Documentation interpretation

Attention to detail

Communication skills

Research payer issues

Education

Bachelor's degree or equivalent

Tools

NextGen

EHR systems

Practice management systems

Job description

The Coding & Documentation Specialist at University of North Texas - Denton will review clinical documentation to ensure accurate coding and compliant submissions. You will work with clinicians and Billing to strengthen charge capture and reduce denials.

Responsibilities include auditing charts, ensuring CPT/HCPCS/ICD-10-CM alignment, and guiding teams on documentation improvements to optimize reimbursement, while maintaining HIPAA compliance and data confidentiality.