CERTIFIED CODING SPECIALIST JOB DESCRIPTION

A Certified Coding Specialist is the person who decides what a healthcare encounter actually costs. That one-sentence answer conceals a technically demanding role governed by ICD-10-CM, CPT, and HCPCS coding systems, where a missed modifier or a miscoded DRG can trigger a payer denial or a compliance audit. The role sits within health information management or revenue cycle departments, translating clinical documentation - operative reports, progress notes, health risk assessments - into billable, auditable records. Physicians, billing teams, and payer liaisons all depend on the accuracy of this work to keep reimbursement flowing and regulatory exposure low.

As the Certified Coding Specialist, you own the translation of clinical documentation into compliant ICD-10-CM, CPT, and HCPCS codes that determine reimbursement outcomes for commercial, Medicare, and Medicaid payers. You work within a revenue cycle or health information team, collaborating with physicians, coders, and compliance leads to maintain coding accuracy, support chart audits, and ensure every service performed is properly captured and billed.

Career Impact: Earning and maintaining credentials such as CPC, CCS, or CRC through AAPC or AHIMA marks you as a verified coding authority, a distinction that carries weight across hospital systems, physician groups, and managed care organizations.

Business Impact: Accurate code assignment on operative reports and health risk evaluations directly determines reimbursement rates under Medicare and Medicaid, protecting the organization from underpayment and reducing denial rates across payer contracts.

Growth Opportunity: Mastery of risk adjustment coding, HCC methodology, and DRG validation opens advancement paths toward Senior Coding Manager, Coding Education Specialist, or Compliance Auditor roles with broader organizational scope.

• Review clinical documentation including operative reports, progress notes, and health risk assessments to assign accurate ICD-10-CM, CPT, and HCPCS codes.
• Audit medical records to identify coding errors, claim edits, and denial patterns across inpatient, outpatient, and ER encounter types.
• Query physicians and clinical staff when documentation is ambiguous, incomplete, or insufficient to support the assigned diagnosis or procedure code.
• Coordinate with revenue cycle and billing teams on coding-related claim denials, appeals, and compliance issues to resolve outstanding accounts.
• Monitor charge submission workflows to ensure all services are captured, coded, and submitted without revenue leakage or missing charge errors.
• Educate providers and clinical staff on documentation requirements, CPT and ICD-10 changes, and payer-specific coding guidelines.
• Apply Medicare and Medicaid billing rules, CMS guidelines, and HIPAA privacy requirements to all coding and record-handling activities.
• Support internal coding audits and quality improvement initiatives by reviewing assigned charts and reporting discrepancies to supervisory staff.

• High school diploma or equivalent required, with an associate or bachelor's degree in Health Information Management preferred, or equivalent work experience.
• 2 or more years of medical coding experience in a healthcare setting, with demonstrated proficiency in ICD-10-CM, CPT-4, and HCPCS code assignment.
• Active certification in at least one of the following: CPC, CCS, CCS-P, CPC-H, RHIT, or RHIA, maintained in good standing through AAPC or AHIMA.
• Knowledge of Medicare and Medicaid reimbursement structures, payer-specific billing rules, and federal documentation compliance requirements.
• Demonstrated understanding of medical terminology, human anatomy, physiology, and disease processes as applied to coding decisions.
• Working knowledge of HIPAA Privacy and Security Rules as they relate to protected health information handling and medical record access.
• Strong analytical and organizational skills with the ability to meet coding productivity targets and accuracy thresholds under deadline pressure.

• Certified Risk Adjustment Coder (CRC) credential or active experience with Medicare HCC coding and risk adjustment methodology.
• Prior experience with DRG validation, health risk evaluation coding, or PACE program risk adjustment environments.
• Background in coding education, chart abstraction, or provider documentation improvement, with the ability to deliver training to clinical staff.
• Familiarity with revenue cycle quality improvement processes, including denial trend analysis and coding audit program participation.

• Coding accuracy rate, measured as the percentage of charts passing audit review without correction.
• Denial rate attributable to coding errors, tracked against payer-reported remittance data on a monthly basis.
• Chart turnaround time, reflecting the number of records coded within the required billing cycle window.
• Query response rate, measuring the proportion of physician queries resolved within defined timeframes to support timely code assignment.
• HCC capture rate on health risk evaluations, measuring completeness of diagnosis coding against CMS risk adjustment expectations.
• Typical tools: Encoder and grouper software (commonly 3M or Optum EncoderPro); EHR platforms (commonly Epic or Cerner).

• Base Salary Range: $48,000 to $72,000 annually, depending on certification level and setting.
• Bonus: Annual performance bonus of 3 to 7%, tied to coding accuracy and productivity metrics.
• Equity: Not typically offered at this level in healthcare settings.
• Health Benefits: Medical, dental, and vision coverage standard across most hospital and physician group employers.
• PTO: 15 to 20 days annually, plus standard federal holidays.
• Common Perks: Continuing education reimbursement for AAPC or AHIMA recertification, remote or hybrid work options for experienced coders.

Figures are estimates based on general US market benchmarks and may be outdated. Adjust based on location, company size, and seniority level.

Successful completion of a background check and, where applicable, a drug screening is required as a condition of employment in this healthcare role. All qualified applicants will receive consideration without regard to race, color, religion, sex, national origin, disability, age, veteran status, or any other characteristic protected under applicable federal, state, or local law. Reasonable accommodations are available to individuals with disabilities throughout the hiring process. Candidates must be authorized to work in the United States.

The Certified Coding Specialist delivers accurate CPT and ICD-10 code assignments across operative reports and hospital procedures, ensuring all services are properly captured and billed. Working in continuous coordination with physicians, providers, and supervisors, the role supports compliant charge submission and timely resolution of coding discrepancies across the organization.

Key Responsibilities

• Develops and maintains excellent relationships with physicians and all other providers.
• Responds to coding requests and patient billing inquiries in a timely manner.
• Reviews operative reports and selects appropriate CPT and ICD-10 codes for hospital procedures.
• Codes procedural reports with appropriate CPT and ICD-10 codes to match all services performed.
• Assists with annual coding audits and special projects as assigned.
• Reports information from hospital staff or physicians to supervisor when discrepancies are identified.
• Maintains continuous communication with physicians and staff to ensure all services are accounted for.

Required Qualifications

• High school diploma or equivalent required.
• Active coding certification such as CPC or CCS required and must be maintained through AAPC or AHIMA.
• Experience in medical records coding using ICD-10-CM and CPT-4 coding systems required.
• Knowledge of coding changes, payer guidelines, and billing provider requirements.
• Detail-oriented with strong organizational and multitasking skills in a fast-paced environment.
• Proficiency with computer applications and electronic health record systems.
• Excellent communication and interpersonal skills with ability to maintain strict confidentiality.
• Valid state driver's license and proof of insurance required.

Embedded within a hospital health information team, the Certified Coding Specialist analyzes clinical documentation and assigns diagnosis and procedure codes across inpatient, outpatient, ER, rehab, and skilled nursing records following AHA, HCFA, and UHDDS guidelines. Working closely with physicians, clinical departments, and customers, the role ensures accurate DRG assignments and supports compliant reimbursement across all care settings.

Core Functions

• Completes analysis of documentation and assigns codes by body system, organ, etiology, and morphology per AHA ICD-10 and CPT4/HCPCS guidelines.
• Performs queries and obtains documentation required for coding records maintained in other departments.
• Confirms appropriate DRG assignments and codes inpatient, outpatient, ER, rehab, skilled nursing, and recurring records.
• Create presentations, learning materials, handbooks, and other training resources for coding and billing topics.
• Answers customer calls and responds to coding-related inquiries.

Qualifications and Experience

• Hold one of the following certifications: RHIA, RHIT, CCS, or CPC.
• Knowledge of medical terminology, anatomy, physiology, coding application, and disease processes.
• Knowledge of ICD-10, HCPCS, CPT coding conventions, AHA guidelines, UHDDS, and HCFA methodology.
• Proficiency in computer applications including Windows, Excel, hospital information systems, and encoders.
• Must be able to communicate effectively in English, both oral and written.

Reporting to practice and revenue cycle leadership, the Coding Education Specialist leads the design, development, and delivery of coding quality and education programs for all areas supported by Professional Billing. Partnering with physicians, IT, business owners, and third-party vendors, this role advances coding compliance and documentation accuracy to improve reimbursement outcomes across the organization.

Primary Duties

• Assist with development of strategic coding communication and education plans for target audiences and training needs.
• Develop coding content-specific, competency-based, and operational-based educational deliverables with business unit resources.
• Lead training sessions on current billing and coding information for physicians, staff, and revenue cycle teams.
• Provide mentoring and feedback to physicians and third-party vendors to improve coding performance.
• Manage delivery of coding training via instructor-led, virtual, webcast, or web-based methods.
• Perform random chart audits and respond to coding questions from internal and external stakeholders.
• Maintain coding training materials and ensure all content reflects current guidelines.

Education and Experience

• Bachelor's degree or equivalent combination of education and experience required.
• Must hold CCS, CCS-P, CPC, or CPC-H certification through AHIMA or AAPC.
• Minimum three years of experience in E/M and/or surgical coding plus reimbursement activities required.
• Clinical background and previous chart abstraction experience preferred.
• Excellent command of ICD-10, HCPCS, CPT coding conventions, E/M coding, human anatomy, physiology, and pathology.
• Proficiency in a variety of computer hardware and software systems.
• Excellent written and verbal communication, interpersonal, time management, and organizational skills.
• Ability to make independent decisions and work effectively under tight deadlines and high volumes.

Sitting at the intersection of clinical documentation and regulatory compliance, the Medical Coding Specialist assigns ICD-10-CM, CPT, and modifier codes to complex records and acts as liaison between third-party payers and assigned departments. Operating across faculty, residents, staff, and billing teams, the role shapes compliant coding practices and supports training on Medicare billing requirements and federal documentation standards.

Duties

• Review complex clinical documentation and diagnostic results to accurately assign ICD-10-CM codes, CPT codes, and applicable modifiers.
• Audit medical records to identify potential problems with coding and reimbursement such as edits, denials, and appeals.
• Act as liaison between third-party payers and assigned departments for all aspects of professional coding.
• Assist faculty, residents, and staff on medical record documentation standards and coding requirements.
• Assist in presenting training sessions on Medicare billing, federal regulations, and clinical documentation requirements.

Minimum Qualifications

• Associate's degree or equivalent training required.
• Bachelor's degree in medical record administration preferred.
• Minimum one year of medical records coding experience with ICD-10-CM, ICD-10-PCS, and CPT-4 required, or degree in Health Information Management.
• Active certification in CCA, CCS, CPC, or CPC-H preferred and may substitute for experience requirement.
• Knowledge of Medicare billing, federal laws, and clinical documentation guidelines.

A key member of the Revenue Cycle team, the Certified Coding Specialist reviews charts, interprets progress notes and diagnostic reports, and assigns accurate CPT and ICD-10 codes to physician services. Collaborating across coding, billing, and compliance functions, the role ensures claims are processed in line with AAPC credentials, third-party guidelines, and regulatory requirements.

Functions

• Review assigned charts for correct ICD-10 and CPT coding accuracy.
• Interpret progress notes and diagnostic reports to accurately assign CPT and ICD-10 codes to services provided.
• Work with team members to educate Revenue Cycle staff on proper coding practices.
• Coordinate with the Revenue Cycle Department on coding issues relating to claim processing.
• Research coding questions to remain compliant with third-party and regulatory guidelines.
• Maintain coding credentials through AAPC.

Skills and Qualifications

• High school diploma or GED required, associate degree preferred.
• Must hold CPC or CRC credentials through AAPC with minimum two years of experience with CPT/ICD-10/HCPCS coding of physician services preferred.
• Knowledge of insurance industry, medical terminology, and anatomy required.
• Excellent computer skills with strong oral and written communication skills.
• Detail-oriented with strong organizational skills and ability to adapt to changing priorities and work volumes.

Accurate Medicare and Medicaid reimbursement depends on the Certified Coding Specialist, who reviews medical information, applies ICD-9-CM and CPT coding methodology, and coaches Coding Specialist staff on billing processes, procedures, and systems. Based within a Coding services team and serving as a liaison to healthcare professionals, the role drives quality improvement across contract deliverables and ensures compliance with HIPAA and payer-specific billing rules.

Accountabilities

• Review medical information to collect data, ensure appropriate billing, and follow up on questions from nurse and physician reviewers.
• Apply knowledge of Medicare and Medicaid rules and regulations pertaining to appropriate billing and coding of accounts.
• Provide coaching and training to Coding Specialist staff on processes, procedures, and systems used within Coding services.
• Identify and coordinate routine contract deliverables including client reports, contract logs, and other reports for internal and external customers.
• Offer quality improvement suggestions on project protocols and facilitate quality improvement plan development as requested.
• Communicate with healthcare professionals as a liaison regarding contract specifications and escalate unresolved concerns to management.
• Provide IT with system and user requirements, perform user testing, and identify system enhancements and functionality errors.

Background and Experience

• Demonstrated proficiency in medical record analysis and ICD-9-CM and CPT coding methodology.
• Advanced knowledge of medical codes, coding conventions, and rules.
• Demonstrated experience in medical review, chart audits, and quality improvement processes.
• Working knowledge of HIPAA Privacy and Security Rules.
• Ability to analyze information, use logic to address work-related issues, and maintain careful attention to detail.
• Strong customer service, public relations, and team facilitation skills.
• Ability to build relationships internally and externally, multitask, and travel up to 10% based on business needs.

As the Certified Coding Specialist, this role leads the accurate assignment of CPT and ICD codes to healthcare claims for commercial and government insurance reimbursement, managing code assignments from final operative reports, office notes, and ER consultations. The Revenue Cycle team relies on this work to maintain compliant billing, optimize physician coding practices, and ensure complete documentation across all clinical encounters.

Scope of Work

• Maintain comprehensive understanding of coding rules and guidelines to facilitate communication and policies with internal staff.
• Facilitate appropriate clinical and operative report documentation to accurately reflect level of services and acuity of conditions in medical records.
• Code from final surgical, procedural operative reports, and office notes and file charges to appropriate insurance carriers or review coding by external vendors.
• Educate internal staff on clinical documentation needs, coding guideline changes, and reimbursement issues.
• Route operative, procedure, ER, and consultation reports to internal and external coding vendors.
• Create encounters for ER, consultation, and other non-scheduled visits and surgeries.
• Work with Coding Team Lead and Revenue Cycle Supervisor to identify documentation issues and optimize coding practices for compliance and revenue purposes.

Professional Experience

• High school diploma or equivalent required.
• Credentialed coder certificate such as CPC, CCS, CPMA, CCDS, RHIT, or RHIA preferred.
• Minimum three years of medical coding experience preferred.
• Current knowledge of reimbursement and coding structures specifically Medicare and Medicaid.
• Strong broad-based clinical knowledge of pathology and physiology of disease processes preferred.
• Experience with electronic medical records or electronic health record systems preferred.
• Microsoft Excel and Word experience preferred.
• Excellent interpersonal, written, and verbal communication skills with valid WI Driver's License required.

Certified Coding Specialist owns ICD-10 code assignment for Health Risk Evaluations of Medicare and Medicaid members, reviewing assessments for accuracy, completeness, and compliance with CMS guidelines under the supervision of the Senior Coding Manager. The work directly supports Medicare Risk Adjustment payment accuracy by ensuring all clinically identified diagnoses are captured, coded, and aligned with HCC coding protocol and organizational compliance standards.

Day-to-Day Responsibilities

• Review health risk assessments and evaluations to determine completion and compliance with CMS guidelines.
• Assess accuracy, completeness, specificity, and appropriateness of diagnosis codes in health risk assessments and evaluations.
• Assign all ICD-9/10 codes clinically identified and supported in assessments and evaluations on a timely basis.
• Apply advanced knowledge of Medicare HCC coding to ensure the organization follows Medicare coding protocol for payment of claims.
• Identify, correct, and report coding problems to integrate coding compliance standards into coding practices.
• Make recommendations for coding policy changes and complete special projects as assigned by management.
• Maintain coding certification and ensure security and privacy of all protected health information accessed during work activities.

Knowledge Skills and Abilities

• Must hold an active CPC, CPC-A, COC, CCS, CCS-P, or CCA certification in good standing.
• CRC preferred, ICD-10 Coding Certification required.
• Minimum 0-10 years of ICD-9/10 coding experience with prior healthcare coding experience preferred.
• Experience and knowledge of Medicare HCC coding and risk adjustment preferred.
• Advanced knowledge of medical terminology, abbreviations, anatomy and physiology, major disease processes, and pharmacology.
• Prior medical chart auditing and quality experience preferred.

The Certified Coding Specialist delivers accurate ICD and CPT code assignments from participant medical records to support data retrieval, analysis, and claims processing within a PACE risk adjustment environment. Working in coordination with physicians, clinicians, and site management, the role ensures RAPS and charge ticket documentation is complete, timely, and fully compliant with AHIMA, AAPC, and CRC certification standards.

Work Activities

• Review and evaluate participant medical records to identify diagnoses and procedures and accurately assign and sequence ICD and CPT codes.
• Query physicians and clinicians when provided information is inadequate, ambiguous, or unclear for coding purposes.
• Ensure accurate and complete client care documentation is completed timely in preparation for billing including RAPS and charge tickets.
• Monitor records that are not completed, coded, billed, or rejected and take appropriate action.
• Attend educational opportunities to enhance knowledge in coding and reimbursement systems and maintain certification from AHIMA or AAPC.

Experience and Qualifications

• Certified Coding Specialist through AHIMA or Certified Professional Coder through AAPC required, with CRC required within one year of hire.
• Minimum two years of experience in a risk adjustment coding environment or healthcare institution preferred.
• Formal training in ICD and CPT coding or equivalent work experience required.
• Demonstrates knowledge of medical terminology, human anatomy, physiology, and disease processes.
• Strong analytical, organizational, and interpersonal skills with ability to meet strict deadlines and prioritize multiple tasks.
• Ability to travel 10% of the time and work effectively as part of a team.

Embedded within a Central Billing Office and clinical site network, the Certified Coding Specialist builds provider compliance through daily charge review, chart audits, and hands-on coding instruction across all clinical locations. Working closely with billing specialists, providers, and compliance teams, the role ensures missing charges are resolved, new services are correctly reimbursed, and all coding aligns with federal, state, and payer-specific requirements.

Operational Focus

• Conduct daily review of all charges to ensure provider coding is compliant with national coding and payer-specific guidelines.
• Assist with chart audits to ensure services are coded correctly following federal, state, and payer-specific requirements.
• Provide coding instructions and input on all coding changes following federal, state, and payer reimbursement requirements.
• Review hospital and invoice services to ensure correct coding and perform data entry and reconciliation of daily batches.
• Maintain the daily missing charge process to ensure missing charges are resolved without lost revenue.
• Research new services offered and ensure appropriate reimbursement coverage.

Position Requirements

• Associate degree or combination of relevant education and experience required.
• Certification as a CPC required.
• Minimum 1-2 years of professional coding experience required.
• Experience in coding, chart auditing, and provider education preferred, with previous billing experience an advantage.
• Knowledge of chart auditing following correct coding guidelines and patient billing policies and procedures.
• Excellent customer service with strong written and oral communication skills.
• Ability to work independently and as a team member with minimal supervision and maintain active professional development.