Coding Specialist

Bournewood Health Systems; Boynton Beach (FL); Presencial; USD 55.000 - 75.000; Jornada completa

Descripción de la vacante

Bournewood Health Systems is seeking a Coding Specialist to review patient records and assign ICD-10-CM codes and procedures in a mental health and substance use treatment environment.

The ideal candidate holds CPC or CCS credentials, demonstrates strong medical terminology knowledge, and is proficient with EHR and billing software, ensuring HIPAA-compliant coding and accurate billing.

Formación

• Strong grasp of medical terminology.
• CPC or CCS credential required.
• Excellent attention to detail and accuracy.
• Proficient with EHR and billing software.
• Experience with psychiatric/h mental health coding is a plus.
• Knowledge of HIPAA and regulatory requirements.

Responsabilidades

• Review patient medical records to assign ICD-10-CM and procedures.
• Ensure codes reflect diagnoses, services and level of care.
• Query clinicians for clarification when documentation is unclear.
• Maintain PHI confidentiality and HIPAA compliance.
• Assist with audits, quality assurance and compliance activities.
• Collaborate with billing, utilization review and administrative teams.

Conocimientos

Medical terminology

CPC/CCS credential

Attention to detail

EHR proficiency

Medical coding

Communication

Regulatory compliance

Herramientas

EHR systems

Medical billing software

Descripción del empleo

Position SummaryThe Coding Specialist is responsible for reviewing patient medical records and accurately translating diagnoses, treatments, and procedures into appropriate universal alphanumeric medical codes. This position ensures clinical documentation is accurately coded in accordance with applicable coding guidelines, regulatory requirements, and organizational standards. The Coding Specialist plays an important role in supporting accurate billing, reimbursement, medical record integrity, and compliance within a mental health and substance use treatment environment.Essential Duties and ResponsibilitiesReview 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 & SkillsStrong grasp of medical terminologyMust 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 QualificationsExperience 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 CompetenciesAccuracy and attention to detailMedical terminology and coding knowledgeKnowledge of behavioral health and substance use documentationConfidentiality and professionalismEffective communicationCritical thinking and problem-solvingOrganization and time managementRegulatory and compliance awarenessTeamwork and collaboration