Medical Coding Specialist

Trillium Health; City of Rochester (NY); On-site; USD 50,000 - 80,000; Full time

Job summary

Trillium Health is seeking a Medical Coding Specialist to review medical records and documentation for accurate ICD-10-CM and CPT coding. Under supervision, support compliant billing practices, maximize reimbursement, and ensure adherence to regulations for FQHCs.

The role collaborates with providers and billing staff to resolve coding issues and promote best practices in clinical documentation and coding accuracy. Strong attention to detail is essential.

Qualifications

• Associate degree in Health Information Management or related field required.
• Professional coding certification (CPC, CCS, or equivalent) required.
• Minimum 6 months of professional fee coding experience.
• Knowledge of FQHC billing and reimbursement regulations.

Responsibilities

• Code diagnoses and procedures using ICD-10-CM and CPT.
• Review patient records and documentation for coding accuracy.
• Clarify documentation with providers to ensure complete coding.
• Ensure timely submission of coding information to support reimbursements.
• Maintain confidentiality and HIPAA compliance.

Skills

ICD-10-CM

CPT coding

Medical terminology

Attention to detail

FQHC billing knowledge

EPIC experience

Communication skills

Team collaboration

Education

Associate degree in health information management

Professional coding certification (CPC/CCS)

Tools

EPIC

Job description

Job SummaryThe Medical Coding Specialist is responsible for reviewing medical records and encounter documentation to ensure accurate, complete, and compliant coding in accordance with ICD-10-CM and CPT guidelines. Under the supervision of the Director of Revenue Cycle and Billing, this role supports compliant billing practices, maximizes reimbursement, and ensures adherence to federal, state, and payer regulations, including those specific to Federally Qualified Health Centers (FQHCs).

Job Title: Medical Coding Specialist
Department: Revenue Cycle
Position Type: Full-Time
FLSA: Non-Exempt
Job SummaryThe Medical Coding Specialist is responsible for reviewing medical records and encounter documentation to ensure accurate, complete, and compliant coding in accordance with ICD-10-CM and CPT guidelines. Under the supervision of the Director of Revenue Cycle and Billing, this role supports compliant billing practices, maximizes reimbursement, and ensures adherence to federal, state, and payer regulations, including those specific to Federally Qualified Health Centers (FQHCs).

The Medical Coding Specialist collaborates closely with providers, billing staff, and other members of the healthcare team to clarify documentation, resolve coding issues, and promote best practices in clinical documentation and coding accuracy.

Duties/Responsibilities

• Medical Coding
• Review and analyze patient records and clinical documentation to ensure completeness and accuracy for coding purposes.
• Assign and sequence diagnosis and procedure codes using ICD-10-CM and CPT for all services rendered.
• Apply coding guidelines and regulatory requirements to ensure correct code assignment and compliance.

Compliance and Accuracy

• Adhere to national coding standards, payer policies, and regulatory requirements.
• Stay current on coding rules, regulations, and industry trends through ongoing education and training.

Collaboration with Healthcare Staff

• Communicate with providers to clarify missing, incomplete, or unclear documentation.
• Provide education and feedback to clinical staff on documentation best practices to support accurate coding.
• Participate in team meetings related to patient care, billing, and coding updates.

Billing Support

• Accurately translate medical procedures and diagnoses into codes for submission to payers.
• Ensure timely submission of coding information to support claims processing and reimbursement.
• Collaborate with billing staff to resolve coding-related claim issues.

Record Maintenance

• Maintain strict confidentiality of patient information in compliance with HIPAA and privacy laws.
• Ensure coded medical records are stored securely and accurately.
• Keep coding manuals and guidelines current and updated.

Professional Development and Other Duties

• Pursue ongoing professional development to remain proficient in medical coding.
• Attend workshops, seminars, and training sessions as needed.
• Serve as a resource or mentor to less experienced coding staff when applicable.
• Assist with automation of cash receipt applications and perform other duties as assigned.

Required Skills/Abilities

• Proficiency in medical terminology, ICD-10-CM, and CPT coding systems
• Strong attention to detail and accuracy
• Knowledge of FQHC billing and reimbursement regulations
• EPIC experience preferred.
• Effective written and verbal communication skills
• Ability to work collaboratively with clinical and administrative teams
• Ability to relate to individuals from diverse backgrounds, cultures, races, sexual orientations, and gender identities

Education and Experience

• Associate’s Degree in Health Information Management or a related field required
• Professional coding certification required (CPC, CCS, or equivalent)
• Minimum of 6 months of professional fee coding experience
• Commitment to continuous learning and staying current with coding regulations and healthcare requirements

Physical Requirements

While performing the duties of this job, the employee is regularly required to sit, stand, walk, use hands to finger, handle or feel; reach with hands and arms; and talk or hear. The employee may occasionally need to stoop, bend, and lift or move up to 25 pounds. Specific vision abilities include close vision, distance vision, peripheral vision, depth perception, and the ability to adjust focus.

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.