CLINICAL CODING SPECIALIST JOB DESCRIPTION

Clinical Coding Specialists translate patient encounters into the structured diagnostic and procedural code sets - ICD-10-CM, CPT, and HCPCS - that drive claims, support compliance, and feed institutional quality reporting. The role sits within health information management, working daily against CMS and AHA coding guidelines while querying physicians, resolving documentation gaps, and sustaining data integrity across outpatient and inpatient records. Certifications from AHIMA or AAPC define professional standing in this field and are often required from day one.

As the Clinical Coding Specialist, you assign and validate diagnostic and procedural codes across patient encounter types, ensuring that every submission meets payer requirements and federal coding standards while protecting the organization's revenue integrity. You operate within the health information or revenue cycle department, collaborating with physicians, billing teams, and compliance leadership to close documentation gaps and resolve coding edits before claims submission.

Career Impact: Earning and maintaining credentials such as CCS, CPC, or RHIT from AHIMA or AAPC marks you as a recognized coding authority, a standing that translates directly into specialty and senior-level opportunities across provider organizations.

Business Impact: The codes you assign determine what the organization bills, what it collects, and whether it passes a payer audit - a single miscoded encounter can trigger a denial cascade or a compliance review.

Growth Opportunity: Experience across multiple specialty service lines, combined with HCC and risk-adjustment exposure, positions coders for advancement into coding supervision, CDI, or compliance auditing roles.

• Assign ICD-10-CM, CPT, HCPCS, and modifier codes to outpatient and inpatient encounters based on complete medical record review.
• Query attending physicians when documentation is ambiguous, incomplete, or insufficient to support accurate code selection.
• Audit coded records for accuracy, completeness, and compliance with CMS, AMA, and AHA official guidelines.
• Identify and report documentation deficiencies, contributing to provider education initiatives and compliance training.
• Resolve coding edits and claim denials through secondary review of medical record documentation and code assignments.
• Monitor chronic condition capture, including HCC code validation, to ensure risk-adjusted submissions reflect documented clinical findings.
• Compile production and accuracy data, reporting findings to coding leadership within established turnaround standards.
• Maintain current knowledge of coding classification updates through continuing education, AAPC or AHIMA seminars, and institutional coding meetings.

• Associate's degree in Health Information Management, Healthcare Administration, or a related field, or equivalent work experience.
• Three or more years of clinical coding experience in outpatient, inpatient, or multi-specialty settings, with demonstrated accuracy under production standards.
• Active coding credential from AHIMA (CCS, CCA, RHIT, or RHIA) or AAPC (CPC, COC, or CPC-A) at time of hire or within six months.
• Thorough knowledge of ICD-10-CM, CPT-4, and HCPCS Level II coding systems and their governing guidelines.
• Working knowledge of CMS reimbursement frameworks, including National Correct Coding Initiative edits and Limited Coverage Diagnosis policies.
• Demonstrated ability to query physicians and communicate documentation requirements in a professional, clinically grounded manner.
• Strong analytical and decision-making skills, with the ability to interpret ambiguous clinical documentation independently.

• Bachelor's degree in Health Information Management or a healthcare-related field.
• Experience with HCC or risk-adjustment coding in Medicare Advantage, ACO, or Direct Contracting Entity environments.
• Familiarity with inpatient PCS coding and DRG-based reimbursement methodologies.
• Prior involvement in coding compliance audits, denial management workflows, or provider education programs.

• Coding accuracy rate at or above department threshold, measured through regular quality audits of assigned records.
• Claim denial rate attributable to coding errors, tracking downstream impact of code assignments on first-pass adjudication.
• Daily and weekly production volume meeting departmental turnaround standards for encounter type and specialty.
• HCC capture rate per pre- and post-appointment review cycle, reflecting completeness of chronic condition documentation.
• Physician query response rate and resolution time, indicating effectiveness of documentation improvement collaboration.
• Typical tools: EHR platforms (commonly Epic or Cerner); encoder and abstracting systems (commonly 3M Codefinder or similar).

• Base Salary Range: $52,000 to $75,000 annually, depending on credentials and specialty experience.
• Bonus: Annual performance bonus of 3% to 6%, tied to accuracy and production metrics.
• Equity: Not typical for this role in healthcare provider settings.
• Health Benefits: Medical, dental, and vision coverage; employer contribution varies by organization.
• PTO: 15 to 20 days annually, plus observed federal holidays.
• Common Perks: Continuing education reimbursement, AHIMA or AAPC membership support, remote or hybrid coding arrangements common in larger health systems.

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

Employment contingent on successful completion of a background check and, where applicable, drug screening consistent with healthcare regulatory requirements. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, disability, genetic information, veteran status, or any other characteristic protected under applicable federal, state, or local law. Reasonable accommodations are available for individuals with disabilities throughout the application and employment process. Candidates must be authorized to work in the United States.

The Clinical Coding Specialist owns the assignment and validation of ICD-10, CPT, HCPCS, and modifier codes drawn from patient encounter records, auditing professional services against CMS and AMA rules to protect revenue integrity and compliance. Reporting to coding and billing leadership, the Clinical Coding Specialist collaborates with physicians and management to resolve documentation gaps, coding edits, and denials across complex and multi-specialty service lines.

Key Responsibilities

• Assign appropriate modifiers and apply guidelines as indicated through the Limited Coverage Diagnosis and the National Correct Coding Initiative.
• Maintain thorough knowledge and understanding of institutional coding policies and procedures.
• Maintain knowledge of ICD-10-CM, HCPCS, and CPT-4 coding guidelines according to CMS, AMA, AHA, and other official sources.
• Conduct coding and compliance research as necessary.
• Maintain coding knowledge and skills through attending continuing education activities and reviewing pertinent literature.
• Attend institutional coding meetings, AAPC/AHIMA seminars, and other educational forums.
• Meet or exceed department production and accuracy standards.
• Query physicians when code assignments are not straightforward or when documentation is inadequate, ambiguous, or unclear for coding purposes.
• Identify and apply knowledge of global periods and modifiers.
• Identify and report documentation issues and participate in team education activities.
• Serve as a resource concerning clinical coding practice, policies, and procedures.
• Initiate high-level decision-making by auditing professional services according to CMS and AMA rules and regulations.
• Resolve coding edits and denials by performing second review of medical record documentation and code assignments.
• Review and respond to coding concerns from billing or management.
• Compile reports with pertinent statistical data for review by management.

Required Qualifications

• Associate's degree in Health Information Management, Healthcare Administration, or related healthcare field.
• Bachelor's degree in Health Information Management, Healthcare Administration, or related healthcare field.
• Equivalent experience may substitute for required education on a one-to-one basis.
• Registered Health Information Administrator (RHIA) by AHIMA.
• Registered Health Information Technician (RHIT) by AHIMA.
• Certified Coding Specialist (CCS) by AHIMA.
• Certified Coding Associate (CCA) by AHIMA.
• Certified Professional Coder (CPC) by AAPC.
• Certified Professional Coder - Associate (CPC-A) by AAPC.
• Certified Outpatient Coder (COC) by AAPC.
• Five years of clinical coding experience for complex or multi-specialties, or three years with preferred degree.
• Three years of inpatient coding experience with PCS experience.
• Flexible and adaptable to changing work assignments.

Embedded within the Care Management Team, the Clinical Coding Specialist delivers pre- and post-appointment medical record reviews for Medicare Advantage enrollees to identify and validate chronic condition capture for HCC coding and physician incentive programs. Working closely with providers, medical office staff, and health plan representatives, the Clinical Coding Specialist supports ICD-10 compliance, provider education, and accurate data collection across assigned populations.

Core Functions

• Evaluate patient medical records and health plan reports to identify potential chronic conditions to be addressed by healthcare providers.
• Complete post-appointment reviews to assess HCC capture by providers and document findings.
• Work with team to ensure ICD-10 codes submitted by physicians are supported by documentation and provide feedback to inform physician education.
• Review, assess, and provide feedback to mid-level providers conducting home visits.
• Document additional HCC codes, when clinically indicated, on the ICE file.
• Report findings of noncompliance for issues not related to HCC in the Secondary Pursuit file.
• Collaborate with team members to research and answer coding questions that may arise.
• Assist in education of providers and staff regarding coding procedures and policies to ensure compliance.
• Respect patients by recognizing their rights and maintaining confidentiality.
• Promote a team approach by encouraging communication among all members of the care team.
• Accomplish delegated tasks on time and meet daily and weekly job goals.
• Communicate with providers regarding HCC capture via the EHR tasking system.
• Maintain excellent customer relationships with providers, medical office staff, other department staff, and health plan representatives.
• Assist in the training and orientation of new staff as directed.

Qualifications & Experience

• High school diploma or equivalent.
• CPC certification required.
• CRC certification preferred.
• Minimum of one to two years of current medical background with chart review experience.
• One year of previous recent procedural and diagnosis coding, or equivalent work experience.
• Two years of customer service experience in a healthcare-related setting.
• Working knowledge of Risk Adjustment or HCC coding.
• Experience with Direct Contracting Entity or Accountable Care Organization environments.
• Working knowledge of medical terminology, anatomy and physiology, disease processes, and pharmacology.
• Expertise in ICD-10-CM, CPT, and RAF coding.
• Proficient in using multiple electronic health record systems concurrently.
• Strong written, verbal, and listening communication skills.
• Demonstrates critical thinking skills, sound judgment, and a solid sense of accountability.
• Detail-oriented and able to work as a collaborative and positive team member.
• Demonstrates a professional demeanor and excellent customer service skills.
• Self-motivated and able to ask for assistance when needed.
• Flexible and adaptable to change.

Reporting to Payment Integrity leadership, the Clinical Coding Specialist leads medical records review within the claim adjudication process, performing quality audits, validating code accuracy, and identifying overpayments through Retrospective Data Mining and Pre-Payment Cost Avoidance initiatives. Partnering with Medical Directors and Utilization Management, the Clinical Coding Specialist contributes to strategies that recover overpayments and establish prospective internal controls across individual provider and program-level coding practices.

Primary Duties

• Investigate, review, and provide clinical and coding expertise in the application of medical and reimbursement policies within the claim adjudication process through medical records review.
• Serve as a Subject Matter Expert, performing medical record reviews to include quality audits, validation of accuracy and completeness of all coding elements, and medical necessity reviews.
• Provide guidance related to Payment Integrity initiatives to include concept and cost avoidance development.
• Collaborate cross-functionally with Medical Directors, Utilization Management, and other internal teams to assist in identification of overpayments.
• Serve as a Subject Matter Expert for all Payment Integrity functions, including Retrospective Data Mining and Pre-Payment Cost Avoidance.
• Identify trends and patterns in overall program and individual provider coding practices.
• Support the creation and execution of strategies to determine impact of opportunity, recover overpayments, and establish prospective internal controls to prevent future overpayments.

Skills & Qualifications

• Certified Professional Coder (CPC), or willingness to obtain within 6 months of hire date.
• Inpatient Coder with RHIT or RHIA preferred.
• CES or equivalent clinical claims editing system Subject Matter Expert designation preferred.
• Five or more years of experience in the health insurance industry.
• Two or more years of experience with health insurance claims.
• Two or more years of experience with medical records review and auditing.
• Two or more years of experience in Utilization Management.
• Experience interpreting provider contractual agreements.
• Experience with Fraud, Waste, and Abuse programs or previous work within Payment Integrity.
• Experience working with federal contracts preferred.
• Proficiency in performing financial analysis and auditing, including statistical calculation and interpretation.
• Proficiency in various claims payment methodologies, including capitation, fee-for-service, DRG, percent-of-charge, and OPPS.
• Proficient in using claims platforms such as UNET, Pulse, NICE, Facets, Diamond, or similar systems.
• Proficient in Microsoft Office applications including Word, Excel, PowerPoint, and Visio.
• Experience with public speaking and presenting to large audiences, including executives and medical directors.

Sitting at the intersection of clinical documentation and national reporting compliance, the Clinical Coding Specialist accurately codes and abstracts outpatient records - emergency, day surgery, and clinic visits - using ICD-10-CA/CCI classification in accordance with CIHI and MOHLTC provincial standards. Operating across health information management and clinical departments, the Clinical Coding Specialist ensures data integrity and timely submission to the National Ambulatory Care Reporting System while conducting routine quality audits against Canadian Coding Standards.

Duties

• Collect a predefined data set and apply the ICD-10-CA/CCI classification methodology for statistical and clinical data.
• Abstract data into the 3M Health Data Management software application and 3M Codefinder tool.
• Code and abstract for the National Ambulatory Care Reporting System.
• Thoroughly analyze patient health records to accurately reflect resource utilization.
• Assign appropriate diagnostic and intervention codes following Canadian Coding Standards.
• Abstract specialized data sets applicable to outpatient visits.
• Perform routine data quality checks and audits to ensure data integrity and consistency.
• Meet internal turnaround times for data submission.
• Attend educational seminars and conferences as required and for ongoing self-development.

Experience & Qualifications

• Graduate of a recognized Health Information Management program.
• Certified with the Canadian College of Health Information Management and must be an active member in good standing.
• Two to three years of previous NACRS coding and abstracting experience preferred.
• Experience with specialized health records and hospital applications including ADT, clinical information systems, 3M Codefinder, and abstracting systems.
• Proven knowledge of current DAD/NACRS abstracting and Canadian Coding Standards (v2018) required.
• Proven knowledge of ICD-10-CA/CCI coding nomenclature.
• Knowledge of inpatient and ambulatory grouping and weighting methodologies (CMG+/CACS) preferred.
• Knowledge of MOHLTC Health System Funding Reform methodology and Quality Based Procedures preferred.
• Computer proficiency in a Windows environment and MS Office applications.
• Strong judgment and decision-making skills.
• Excellent teamwork, interpersonal, and communication skills.
• Able to work independently and collaboratively within a team environment.