Coding and 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

Title: Coding & Documentation Specialist

Employee Classification: Coding & Doc Specialist

Campus: University of North Texas Health at Fort Worth

Division: HSC-Health Systems

SubDivision-Department: HSC-Health Systems & Clinical Aff

Department: HSC-HSC Health Administration-335001

Job Location: Fort Worth

Salary: Salary Commensurate with Experience

FTE: 1.000000

Retirement Eligibility: TRS Eligible

About Us - Values Overview

Welcome to the University of North Texas System. The UNT System includes the University of North Texas in Denton and Frisco, the University of North Texas at Dallas and UNT Dallas College of Law, and University of North Texas Health Fort Worth. We are the only university system based exclusively in the robust Dallas-Fort Worth region. We are growing with the North Texas region, employing more than 14,000 employees, educating a record 49,000+ students across our system, and awarding nearly 12,000 degrees each year.

We are one team comprised of individuals who are committed to excellence, curiosity and innovation. We are transforming lives and creating economic opportunity through education. We champion a people-first values-based culture where We Care about each other and those we serve. We believe that we are Better Together because we foster an environment of respect, belonging, and access for all. We demonstrate Courageous Integrity through setting exceptional standards and acting in the best interest of our communities. We are encouraged to Be Curious about opportunities for learning, creating, discovering, and innovating, and are encouraged to learn from failure. Show Your Fire by joining our team and exhibiting your passion and pride in your work as part of our UNT System team.

Learn more about the UNT System and how we live our values at www.UNTSystem.edu.

Department Summary

UNT Health Clinical Practice Group is the academic clinical practice for UNT Health. Focused on improving health outcomes to build a healthier community. Clinical Practice Group primary and multispecialty care clinics are located on the UNT Health campus in Fort Worth. Our care teams extend to local hospitals, surgery centers, long-term and continuing care centers, and mobile and in-home care. The Clinical Practice Group's interprofessional teams work collaboratively to achieve an optimized treatment plan tailored to the individual patient. Physicians, nurse practitioners, physician assistants, physical therapists, pharmacists, social workers, psychologists, specialized technicians, and nurses work together while intentionally integrating health care students, residents, and fellows to deliver care to our community.

Position Overview

The Coding and Documentation Specialist is responsible for reviewing clinical documentation and coding to ensure services are accurately documented, coded, and submitted in accordance with federal, state, payer, and organizational requirements. This position works closely with clinicians, Billing, and other departments to improve documentation quality, ensure complete charge capture, reduce coding-related denials, and support accurate and timely reimbursement.

The Coding and Documentation Specialist serves as a resource to clinicians regarding documentation and coding requirements and proactively identifies opportunities to improve documentation, coding accuracy, and revenue cycle performance.

Minimum Qualifications

Bachelor's degree or equivalent combination of education and experience.

Knowledge, Skills and Abilities

• Strong knowledge of ICD-10-CM, CPT, HCPCS, and modifier guidelines
• Knowledge of E/M coding and documentation requirements
• Understanding of Medicare, Medicaid, and commercial payer billing requirements
• Knowledge of coding compliance and medical necessity requirements
• Ability to interpret clinical documentation and determine whether reported codes are supported
• Strong analytical and problem-solving skills
• Excellent attention to detail
• Strong written and verbal communication skills
• Ability to communicate effectively and professionally with clinicians
• Ability to research complex coding and payer issues
• Ability to identify trends and recommend corrective actions
• Ability to manage multiple priorities and meet established deadlines
• Proficiency with electronic health record and practice management systems
• Ability to maintain confidentiality and appropriately handle protected health information

Preferred Qualifications

NextGen experience is a plus.

Required License/Registration/Certifications

CPC Certification Required

Job Duties

• Review clinical documentation and coding to ensure 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 that delay billing.
• Work directly with clinicians to resolve documentation and coding concerns and provide ongoing education and guidance.
• 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.
• Partner with Billing team to research and resolve coding-related claim edits and denials.
• Identify root causes of coding and documentation issues and recommend process improvements to prevent recurrence.
• Support accurate capture of applicable quality measures, including HEDIS, CMS Star Ratings, and payer incentive programs.
• Stay current on CPT, HCPCS, ICD-10-CM, CMS, Medicaid, Medicare, and payer-specific coding and documentation requirements
• Participate in Revenue Cycle, compliance, workflow improvement, and clinician education initiatives.
• Maintain confidentiality and comply with HIPAA, organizational policies, and coding compliance standards.

Physical Requirements

• Operating motor vehicles or heavy equipment.
• Repeating motions that may include the wrists, hands and/or fingers.
• Sedentary work that primarily involves sitting/standing.
• Moving about to accomplish tasks or moving from one worksite to another.
• Moving self in various positions to perform tasks in tight and confined spaces.
• Lifting and Moving objects up to 20 pounds.
• Communicating with others to exchange information.

Environmental Hazards

• No adverse environmental conditions expected.

Work Schedule

M-F 8-5

Driving University Vehicle

No

Security Sensitive

This is a Security Sensitive Position.

EEO Statement

The University of North Texas System is firmly committed to equal opportunity and does not permit -and takes actions to prevent - discrimination, harassment (including sexual violence, domestic violence, dating violence and stalking), and retaliation on the basis of race, color, religion, national origin, sex, age, disability, genetic information, or veteran status in its application, employment practices, and facilities; nor permits race, color, national origin, religion, age, disability, veteran status, or sex discrimination and harassment in its admissions processes, and educational programs and activities. UNT System Administration promptly investigates complaints of discrimination, harassment, and related retaliation and takes remedial action when appropriate. System Administration also takes actions to prevent retaliation against individuals who oppose any form of harassment or discriminatory practice, file a charge or report, or testify, assist, or participate in a related investigation or proceeding.