Coding Analyst Job Description

Healthcare reimbursement under Medicare, Medicaid, and commercial payers depends on ICD-10-CM, CPT, and HCPCS codes matching the clinical documentation behind every claim. The Coding Analyst is the professional who checks that fit, working across hospitals, payer organizations, and physician groups to audit codes and flag discrepancies. Errors here carry real financial consequences. Analysts typically hold a CPC, CCS, or RHIT credential and use NCCI edits to catch problems that would otherwise trigger denials or audits from CMS and state Medicaid programs, whether the work sits inside a hospital, a health plan, or a physician practice.

Success as a Coding Analyst means catching coding and documentation errors before they cost the organization money or trigger a payer audit. The position typically sits within a coding, compliance, or revenue cycle team, working alongside billing staff, internal auditors, and clinical or provider stakeholders across the organization to keep every claim defensible.

Career Impact: Coding credentials such as CPC, CCS, or RHIT, paired with hands-on audit and denial-resolution experience, carry real market weight across payers, hospitals, and physician groups.

Business Impact: Accurate coding keeps claims from being denied, delayed, or under-billed, which protects revenue for the organization and speeds up rightful payment for services patients have already received.

Growth Opportunity: Strong performers move toward audit leadership, coding education, or risk adjustment specialties as their credential portfolio, audit caseload, and cross-team exposure meaningfully grow.

• Audit coded claims against clinical documentation and source records to confirm accuracy under ICD-10-CM, CPT, and HCPCS coding guidelines.
• Monitor Medicare, Medicaid, and commercial payer policy changes to keep coding and billing practices compliant.
• Analyze denial and audit trends across claim types to identify recurring coding or documentation problems.
• Resolve claim denials and provider disputes by researching payer guidelines and correcting the underlying coding errors.
• Prepare audit findings, productivity metrics, and trend reports for compliance, billing, and clinical leadership.
• Coach coding staff and providers on documentation gaps identified during regular audits and reviews.
• Collaborate with billing, compliance, and clinical teams to resolve complex or escalated coding questions.
• Maintain required coding certifications and stay current on regulatory and payer guideline updates.

• Bachelor's degree in health information management, business, or a related clinical or administrative field, or equivalent work experience.
• 2 or more years of medical coding or billing experience, with hands-on exposure to claim audits or edits.
• Working knowledge of ICD-10-CM, CPT, and HCPCS coding systems used across hospital, payer, or physician practice settings.
• Coding certification such as CPC, CCS, or equivalent, or ability to obtain one within a defined period.
• Knowledge of Medicare, Medicaid, and commercial payer billing, reimbursement, and claims edit rules.
• Strong analytical and problem-solving skills for reviewing claims, denials, and clinical documentation.
• Excellent written and verbal communication skills for working with clinical, billing, and compliance staff.
• Proficiency with spreadsheet and reporting software for organizing and analyzing coding and claims data.

• Additional credentials such as RHIA, RHIT, or CCS held beyond the minimum certification the role already requires.
• Prior experience with risk adjustment or HCC coding in a value-based care or ACO setting.
• Experience delivering coding education or training sessions to coders, providers, or clinical staff members.
• Background working in an academic medical center, hospital system, or healthcare consulting environment.

• Coding accuracy rate on internal or payer audits, reflecting how often assigned codes match documentation.
• Claim denial rate tied to coding errors, tracking how much rework this role prevents.
• Average turnaround time per audit, measuring how quickly findings reach stakeholders.
• Number of coding disputes resolved per month, showing hands-on problem-solving volume.
• Percentage of required certifications maintained on schedule, reflecting regulatory readiness.

• Base Salary Range: $48,000 to $66,000 per year, depending on certification, setting, and years of experience
• Bonus: Occasional performance bonus, typically 2 to 5 percent of base salary
• Equity: Not typically offered for this role
• Health Benefits: Medical, dental, and vision coverage, often with partial employer premium contribution
• PTO: 15 to 20 days annually, plus standard paid holidays
• Common Perks: Certification exam fees, continuing education credits, and remote work options

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

Employment with the organization is contingent on successful completion of a background check and, where applicable, a drug screening. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, or any other status protected under applicable federal, state, and local law. Reasonable accommodation is available for individuals with disabilities upon request. Candidates must be authorized to work in the United States for this position.

The Coding Analyst owns monthly quality audits of medical coding accuracy, testing operational processes against Quality Auditing Policy and NCCI guidelines to keep coding practices compliant. Reporting within the Medical Services audit function, the analyst shares monthly findings with stakeholders and helps close cost-saving and process improvement opportunities.

Key Responsibilities

• Perform quality audits focused on medical coding principles and guidelines, as well as operational performance and processes as needed.
• Extract precise information from documentation, test results, and reports to audit and ensure appropriate codes were assigned.
• Audit and test ongoing operational processes to assure continued compliance with all requirements regarding coding procedures, practices, and internal processing guidelines.
• Complete audits following Quality Auditing Policy and communicate audit findings to key stakeholders every month.
• Review claims to formulate a synopsis of facts and collaborate with Medical Services regarding the synopsis, and perform special audits as needed to ensure compliance.
• Prepare monthly dashboard reports for Medical Services to use in making adjustments and process improvements per findings as necessary.
• Provide detailed findings for educational opportunities in collaboration with internal stakeholders.
• Research coding and other billing regulatory issues when needed.
• Analyze issues where understanding situations or data requires in-depth knowledge of organizational objectives.
• Respond to concerns and allegations and work with internal stakeholders to develop corrective action plans, and follow up appropriately on issues identified.
• Stay up to date on insurance guidelines, regulations, and medical coding updates and changes through training and use of monthly newsletters and proactively educate departmental staff regarding changes and issues affecting physicians and coding.
• Identify process improvements that could lead to cost savings and enhancement opportunities.

Required Qualifications

• High school diploma or GED, or higher.
• Bachelor's degree or higher.
• Certified Professional Coder (CPC) certification.
• 5 or more years of experience in medical billing and/or coding, including 3 or more years of coding audits or quality assurance, medical claims processing, and developing and presenting audit findings and reports.
• Strong working knowledge of NCCI (National Correct Coding Initiative) guidelines, along with thorough knowledge of anatomy and medical terminology.
• Strong analytical skills, with the ability to manipulate large volumes of data, present results, and work across software applications and systems.
• Working knowledge of Microsoft Excel for analyzing and manipulating data, along with familiarity with Encoder Pro.
• Strong interpersonal, verbal, and written communication skills, with the ability to work well within a team environment.
• Ability to maintain a dedicated, private work area, keep sensitive documents secure, and access an approved high-speed internet connection for remote work.

Embedded within the enterprise Benefits Configuration team, the Coding Analyst II builds code-level benefit definitions that keep member benefits compliant across every state and market the organization serves. Working closely with Configuration, the Policy Department, and Payment Integrity, this analyst resolves benefit conflicts and helps the organization adapt to regulatory and product changes each year.

Core Functions

• Collaborate with Configuration to define business requirements associated with code-level data related to member benefits.
• Inventory and review a catalog of all member benefits.
• Research and interpret complex regulations across all markets to ensure compliance.
• Use correct coding guidelines across all product lines.
• Integrate Essential Health Benefits, prior authorization requirements, state provider agreements, CMS requirements, state-specific regulations, and Mental Health Parity, and resolve information source conflicts.
• Participate in the annual benefit change process with product leads and benefits support analysts.
• Use reports to analyze and stratify data to provide answers to member benefit issues identified within the department or by other departments.
• Collaborate with the Policy Department on payment and medical policy development.
• Collaborate with Payment Integrity to resolve conflicts between benefits and the clinical edit system.
• Investigate and help resolve complex issues.
• Perform and document peer review of code-level benefit definitions.
• Collaborate with Leadership and Benefits Support Analysts to communicate opportunities based on industry standard coding practices.
• Review, respond to, and implement regulatory changes accurately and timely.

Qualifications & Experience

• Bachelor's degree in a related field or equivalent years of relevant work experience.
• Certified Medical Coder (CPC, CCS-P, RHIT, or RHIA) required.
• 2 or more years of medical coding experience, including 2 or more years of managed care experience, preferably in benefits coding, claims processing, or benefit configuration.
• Extensive knowledge of CPT, HCPCS, and ICD-CM codes, other claims-related reference data such as bill types, revenue codes, and places of service, and Medicare, Medicaid, or Marketplace insurance benefits.
• Proven understanding of database relationships and the upstream and downstream impacts of code-level benefit details.
• Advanced computer skills with Microsoft Suite, especially Excel, with Facets knowledge or training preferred.
• Strong critical listening, thinking, and problem-solving skills, with attention to detail and the ability to work independently and within a team environment.
• Strong written and verbal communication skills, with strong interpersonal skills, a high level of professionalism, and the ability to build and maintain strong cross-functional working relationships.
• Ability to manage multiple priorities across markets and requirements.

Reporting to the HID Audit Manager, the Coding Analyst delivers advanced analytical and administrative support for the hospital revenue cycle, retrieving and reconciling data across coding, audit, and billing systems. Partnering with the coding and audit teams, the analyst resolves data discrepancies, trains new staff, and produces reports that guide administrative decision-making.

Primary Duties

• Assess the use of requested information and identify data sources based on management team needs, and retrieve data from appropriate systems.
• Manipulate raw data into a workable or requested format for use in decision-making, and produce accurate reports that meet end user needs.
• Review data and resolve data discrepancies before finalizing reports, and provide a probable reason for demonstrated trends or possible data discrepancies.
• Perform research and accurately assign meaning to data, and make recommendations based on trended data for subsequent actions such as follow-up monitoring.
• Prepare reports for middle-level administrative groups within requested timeframes.
• Support performance improvement by attending meetings, assisting with process improvement, and other collaborative activities as assigned.
• Assist with the training of new staff, volunteers, and contract staff.

Skills & Qualifications

• Associate's degree or college diploma in a health services related discipline or related field required.
• Certified Professional Coder-Hospital license preferred.
• RHIA, RHIT, or CHDA certification preferred.
• 2 or more years of experience with CM, CPT, DRG, or APC methodologies, or data analytics within a healthcare setting.
• 2 or more years of hospital billing experience preferred.
• 2 or more years of acute hospital coding experience required.

Sitting at the intersection of Charge Master management and revenue cycle reimbursement, the Coding Analyst leads root cause analysis on issues that impede accurate hospital billing and reimbursement. Operating across Patient Accounts, Health Information Management, and Finance, this analyst audits patient charges, corrects failed claims, and reconciles charge balancing reports to keep revenue posting accurate.

Duties

• Support strategic and business planning efforts.
• Assist with coordination of Charge Master changes and provide related education to users.
• Perform ad hoc report writing to support information needs.
• Perform root cause analysis for issues that impede the revenue cycle.
• Assist with auditing of patient charges and help coordinate resolution of issues with the Periop charge team and other departments, including HIM and Patient Accounts.
• Provide technical support of departmental business needs as identified.
• Assist with editing and correcting failed claims related to coding by reviewing charts to verify supplies, implants, or devices used and appropriate codes assigned.
• Reconcile charge balancing reports to ensure revenue has posted accurately to patient accounts.

Requirements

• High school diploma or equivalent required.
• CCS, CPC, RHIA, or RHIT certification required.
• 5 or more years of experience in inpatient and outpatient coding, DRG, and APC analysis.
• Proficient in both inpatient and outpatient coding, maintaining proficiency in ICD-9-CM and CPT-4 coding principles.
• Extensive knowledge of billing and payment practices.
• Ability to organize resources and lead projects to meet deadlines as outlined by department leadership.

A key member of the coding education and compliance team at an academic medical center, the Coding Analyst builds coding training programs and audits records from a Level I trauma center for accuracy. Collaborating across Compliance, Clinical Documentation Improvement, and Patient Financial Services, this analyst trains new coders and helps the organization manage coding risk.

Functions

• Serve as an organization resource and content expert for documentation and coding guidelines.
• Provide expert coding content knowledge to staff and other key stakeholders.
• Coordinate with and provide guidance to Compliance, Clinical Documentation Improvement, Utilization Management, Clinical Resource Management, Revenue Integrity, Charge Master Operations, and Patient Financial Services on coding or billing compliance-related issues.
• Monitor developments in related rules, regulations, and coding changes, and make recommendations to maintain coding compliance, quality, and mitigate risk.
• Perform regular coding audits, analyze results, and create audit reports.
• Provide individual and group education and training to coding staff on the results of coding audits.
• Train new coders and coders who have moved to a new coding team.
• Assist in the development and implementation of role-specific coding training, including effective monitoring, auditing, and risk assessment activities.
• Review, analyze, and determine the effectiveness of training, assess effectiveness against workforce and industry key performance indicators, and recommend enhancements.
• Review DRG and CPT claim denials for commercial payers.
• Evaluate billing, coding, and documentation behavior and identify recommendations for improvement.
• Provide consultation and best practice guidance to engage and influence outcomes.
• Maintain written documentation of actions, activities, or assessments in accordance with state and federal law and institutional policies.

Experience & Qualifications

• Bachelor's degree in a health sciences discipline, business administration, or related field, or equivalent combination of education and work experience.
• Certified as a Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist (CCS), Certified Coding Specialist-Physician Based (CCS-P), Certified Professional Coder (CPC), Certified Inpatient Coder (CIC), Certified Outpatient Coder (COC), Certified Interventional Radiology Cardiovascular Coder (CIRCC), or Radiology/Radiation Oncology Certified Coder (RCC/ROCC).
• 4 or more years of increasingly responsible related experience, including coding auditing, analysis, education, and training.
• Extensive knowledge of DRG, ICD, CPT, and HCPCS coding principles and guidelines.
• Proven communication, organizational, analytical, and critical thinking skills, with successful experience working both independently and in teams within a multifaceted, highly matrixed organization.
• Demonstrated ability to establish positive working relationships, effectively manage competing priorities, and accurately complete highly detailed work.
• Ability to manage time effectively in a high-volume, high-accuracy work environment with deadlines, and to communicate effectively with all levels of management and medical staff.
• Ability to maintain confidentiality and work in a collaborative team environment.
• Proficient with the MS Office suite, with basic knowledge of Office 365.
• Experience in an academic healthcare environment, with proficiency in Epic or Cerner products and experience with a 3M encoder preferred.

Accurate Medicare and Medicaid reimbursement depends on the Coding Analyst, who leads the resolution of coding and billing errors across hospital, outpatient, and pharmacy settings using CMS and NCD/LCD guidelines. Serving as a resource for Health Information Management and Patient Financial Services, this analyst tracks denial trends and files appeals to protect reimbursement.

Accountabilities

• Apply in-depth knowledge of Medicare and Medicaid coding and billing guidelines, NCD/LCD, and CMS regulations to analyze and review coding for compliance, medical necessity, and other coding- or billing-specific reasons.
• Review medical record documentation to ensure services are coded and billed with appropriate diagnoses and services.
• Apply in-depth knowledge of industry-standard coding and billing rules to correct errors and resolve problems related to preparing and submitting accurate bills for services provided in hospital, ASC, outpatient, extended care facility, and pharmacy settings, including ICD-9-CM/ICD-10-CM, CPT, and HCPCS code errors.
• Analyze and gather coding trends to present to management and Health Information Management, and identify recommendations for provider training and system inequities.
• Monitor system issues related to coding and billing, including interfaces, charge master, and electronic claims submission.
• Follow up on denials for coding and file appeals as appropriate, and conduct follow-up on claim denials needing coding review.
• Serve as a resource for Health Information Management and Patient Financial Services on issues needing detailed, high-level coding review.
• Respond to internal and external customer coding issues via phone, mail, and other correspondence methods, and conduct appeals and adjustment requests as appropriate.
• Analyze denial trends to provide recommendations to reduce claim denials and optimize reimbursement.
• Participate in monitoring existing and emerging coding and billing compliance risks, identify trends over time, and participate in root cause analysis for preventative measures.
• Participate in ongoing process improvement work and communicate issues and areas of risk to appropriate departments.

Technical Qualifications

• High school diploma or General Education Development (GED) required.
• Professional Coder Certificate, Coding Specialist Certificate, Coding Associate Certificate, Coding Specialist Certificate-Physician Based, Registered Health Information Technician Certificate, or Registered Health Information Administrator Certificate required at hire, or a coding/billing vocational certificate.
• 4 or more years of coding or billing experience.
• 2 or more years of billing with Medicare and Medicaid.
• 2 or more years of Medicare/Medicaid coding experience.
• Knowledge of payer-specific billing regulations, including government programs such as Medicare, Medicaid, CMS, and HCFA.
• Knowledge of HIPAA, WAC, and RCW regulations.

As the Coding Analyst, this role owns faculty billing advocacy for a psychiatry department, training providers on current CPT codes and auditing professional fee documentation for accuracy. The department relies on this work to catch coding outside the norm, identify revenue enhancement opportunities, and keep new physician billing on track.

Activities

• Represent faculty billing and advocate for efficient billing procedures.
• Support Clinical Outreach efforts and ensure that bills accurately move through the billing cycle.
• Work with Compliance to ensure proper coding and accurate, defensible results.
• Train faculty on the latest CPT codes on an ongoing basis.
• Perform audits of documentation and coding of inpatient and outpatient professional fee services.
• Analyze results and identify patterns, trends, and variations in coding and documentation practices.
• Prepare reports of findings and recommendations for improvement for internal review and distribution to department leadership.
• Identify divisions or individual physicians coding outside the norm using billing data, and identify operational deficiencies and target revenue enhancement opportunities.
• Track provider enrollment progress for new physicians and ensure new physicians have a billing number on a timely basis.
• Coordinate updates of paper billing forms and work with IS to ensure electronic billing forms reflect the most current billing codes.
• Work with revenue cycle leadership and division faculty to improve efficiency and timeliness of billing sheet submission.

Position Requirements

• Bachelor's degree and 5 or more years of relevant experience, or a combination of education and relevant experience.
• Certification in CPC, CPMA, or CEMC.
• Demonstrated ability to establish priorities, manage shifting priorities, and handle numerous time-sensitive projects with multiple deadlines.
• Ability to accomplish goals through formal and informal channels, with diplomacy and tact.
• Demonstrated creativity, problem-solving, critical analysis, initiative, judgment, and decision-making skills.
• Demonstrated ability to develop and meet department goals, with solid planning and organizational skills.
• Demonstrated experience working independently and as part of a team, with strong relevant subject matter knowledge.
• Ability to apply critical thinking skills to coding policy interpretation and implementation, working independently and well organized with minimal direction.
• Excellent interpersonal, written, and oral communication skills, effectively communicating both verbally and in writing.
• Strong PC skills with Excel, Word, PowerPoint, and internet-based programs.
• Ability to perform desk-based computer tasks, with occasional standing, walking, and telephone use.

Coding Analyst leads implementation of new and modified claims edits, monitoring their performance across vendors and keeping payment policy aligned with CMS and New York State Department of Health guidelines. The work directly supports providers through written dispute resolutions, escalated appeals, and cross-department collaboration on coding and clinical practice compliance.

Operational Focus

• Identify areas of opportunity for new edits and modifications to existing claims edits.
• Lead implementation efforts for new or modified edits and work with other departments to ensure proper integration with existing systems.
• Monitor and report on the performance of current claims editing packages.
• Support claims editing escalated provider disputes and appeals, and guide claims editing, coding, billing, and payment.
• Research and provide feedback on claims editing performance issues, internally and externally with providers and vendors.
• Work closely with claims editing vendors on maintaining and updating edits as regulatory, legislative, or industry-accepted payment policy requires.
• Collaborate with other departments to improve compliance with coding conventions and clinical practice guidelines.
• Review and respond to written provider disputes, clearly outlining the payment discrepancy to the provider.
• Research post-payment claims and take appropriate action to resolve identified issues within turnaround time and quality standards.
• Navigate CMS and state-specific websites and AMA guidelines, comparing them to current payment policy configuration to resolve provider payment discrepancies.
• Review medical records to ensure coding is consistent with services billed, and process claim adjustment requests following established guidelines.
• Identify and escalate root cause issues to supervisor for review, and act as liaison with other departments on claims payment policy disputes.

Knowledge, Skills & Abilities

• High school diploma or GED from an accredited institution required, or a bachelor's degree in a related field.
• Coding certification from the American Academy of Professional Coders (AAPC).
• Certified Professional Coder (CPC).
• American Health Information Management Association (AHIMA).
• Previous relevant experience in claims editing or coding.
• Demonstrated professional writing, electronic documentation, and assessment skills.
• Good time management, critical and creative thinking, communication, and problem-solving skills.
• Intermediate Outlook, basic Word, Excel, and PowerPoint skills, along with basic Adobe Acrobat skills.
• Knowledge of anatomy, pathophysiology, and medical terminology.

The Coding Analyst oversees coding and billing exceptions for molecular and pathology laboratory claims, resolving the exceptions worklist to keep reimbursement accurate. Reporting within the billing operations team, the analyst partners with internal and outsourced providers to train staff, audit work quality, and maintain accurate payer rate data.

Key Deliverables

• Own review and coding of molecular samples per reports to prepare for billing.
• Resolve the coding exceptions worklist, especially in the area of molecular testing.
• Assist with maintenance of billing rules in master files.
• Analyze and highlight potential issues in billing operations for management regarding reimbursement opportunities.
• Develop analytical trends and provide operational support, train staff, and conduct audits on work quality with internal and outsource providers.
• Analyze errors to determine and present reimbursement opportunities.
• Coordinate with payers and managed care on collection and appeals projects.
• Develop recommendations for corrective action based on quality issues found in data analysis.
• Maintain current knowledge of payer policies to update system practices, including recommendations for new practices or procedures.
• Maintain and update business rules and standard operating procedures as needed.

Professional Experience

• High school diploma or GED required, with a degree in business, finance, or a related discipline preferred.
• Certified Professional Coder certification preferred.
• 3 or more years of experience working in a medical office, laboratory, or central business office performing medical billing and coding.
• Pathology and molecular laboratory coding experience strongly preferred.
• Strong proficiency in Microsoft Office, including Excel and Outlook, as well as 10-key typing skills.
• Ability to work within multiple windows and web-based applications to carry out tasks, demonstrating overall knowledge of the revenue cycle.
• Excellent written and verbal communication skills, with the ability to work on multiple tasks without sacrificing quality, attention to detail, and the ability to interact with staff at all levels.

Embedded within a healthcare revenue integrity consulting practice, the Coding Analyst refines inpatient DRG and ICD-10-CM/PCS coding accuracy across complex client hospital claims of every severity level. Working closely with service line directors and client department heads, this analyst leads education sessions, contributes to publications and presentations, and helps clients strengthen coding and reimbursement performance.

Areas of Ownership

• Review claims at all levels of complexity for inpatient claims using a revenue integrity platform.
• Review whether diagnoses and procedures represented by ICD-10-CM/PCS coding are accurate, and whether DRGs are assigned correctly with all diagnoses, procedure codes, and MCC/CCs identified.
• Support and engage in education presentations, both in person and remotely, associated with audit and review activities.
• Maintain current knowledge of regulatory agency standards, including CMS, OIG, and AHA.
• Consult with client organizations and department heads at the direction of the service line director.
• Collaborate with other service line team members to meet client demands and develop strategies for service line growth and operational improvement.
• Communicate consistently with project team members regarding the status and results of service line business operations.
• Contribute to publications, presentations, and papers on behalf of the organization as requested.

Education & Experience

• Bachelor of Science degree in a related field required.
• Associate's in Health Information Technology minimally acceptable.
• RHIA or RHIT preferred, with CCS credential required.
• 5 or more years of experience with inpatient auditing and reviewing cases.
• Demonstrates competency in the use of computer applications in the EHR, such as Cerner, Epic, or Meditech, and knowledge of DRG grouping software.
• Computer proficiency related to MS Office and in-house proprietary software.
• Demonstrates knowledge in hospital and healthcare settings such as revenue cycle, coding, and reimbursement.
• Knowledge of ICD-10-CM/PCS required, with ICD-10-CM/PCS AHIMA Approved Trainer experience highly desired.
• Excellent oral and written communication skills, including the ability to interact with high levels of management, with attention to detail and the ability to meet targeted deadlines.

Reporting to the Director of Service Operations, the Coding Analyst develops claims editing responses that resolve provider disputes using current coding and clinical guidance. Partnering with Nurse Auditor staff and Account Management, this analyst identifies edit discrepancies and analyzes claim data to protect payment accuracy.

Role Responsibilities

• Review and use the most up-to-date approved coding and clinical sources to respond to disputes and claim corrections, advising personnel of important changes and trends.
• Work closely with Nurse Auditor staff to manage claim matters requiring Chief Medical Officer involvement.
• Assist the department in customizing and creating dispute letters as needed.
• Identify edit discrepancies based on coding guidelines and coding sources, and make recommendations for updates and changes.
• Analyze claim data to support initiatives managed by the Director of Service Operations.
• Work closely with the research team to perform applicable research related to claims editing, including nationally recognized sources and information.
• Identify tools and technologies required to expand products or solutions.
• Partner with Account Management on client-related matters as needed.
• Assist in tracking and monitoring productivity and value with existing and future concepts.
• Maintain awareness of and ensure adherence to standards regarding privacy.

Background & Experience

• LPN or RN required.
• Coding certification CPC or CCS required.
• Code editing experience preferred.
• Experience and working knowledge of health insurance, Medicare guidelines, and various healthcare programs.
• Understanding of outpatient coding and billing rules.
• Excellent written and verbal communication skills, highly organized with attention to detail.
• Strong analytic skills regarding data requests and reporting.
• Clinical skills to evaluate appropriate medical record coding.

Sitting at the intersection of clinical documentation and risk adjustment coding, the Coding Analyst advances HCC RAF accuracy by reviewing patient charts, labs, and consultant notes for potential chronic diagnoses. Operating across primary care providers and clinical staff, this analyst delivers direct coding education, post-visit chart reviews, and audit program oversight that improve documentation accuracy.

Job Functions

• Identify Hierarchical Condition Category (HCC) Risk Adjustment Factor (RAF) relevant ICD-10 codes and prepare charts accordingly.
• Review patient charts in the electronic medical record to identify labs, consultant notes, medications, radiology reports, and payor reports to flag potential chronic diagnoses with sufficient accuracy and granularity to assist primary care providers.
• Improve clinician performance by meeting with providers, sharing reports, and reviewing specific patient charts to identify opportunities.
• Assist in ICD-10 supplemental code submission per health plan requirements and department policies.
• Complete post-visit chart reviews of medical record documentation and remove or add ICD-10 codes as appropriate.
• Provide direct coding education to providers and clinical staff.
• Collaborate with clinicians to identify ICD-10 conditions and provide feedback on coding accuracy.
• Share feedback respectfully about instances of lack or poor documentation or noncompliance detected through auditing.
• Research and provide courteous, accurate, and timely responses to physician inquiries relating to HCC risk adjustment.
• Administer audit program development and execution.

Required Qualifications

• High school diploma required, with a BA or BS in healthcare or an equivalent field preferred.
• Certified Professional Coder (CPC, CCS-P, or other coding certification) preferred.
• 4 to 8 years of ICD diagnosis coding or risk adjustment coding experience.
• Experience with pre-visit and post-visit chart or medical record reviews.
• Excellent computer skills with Excel, Word, and PowerPoint.
• Astute problem-solving skills, with demonstrated data analysis and reporting skills.
• Prior work within electronic medical records such as Athena or eClinicalWorks preferred.

A key member of a coding compliance and training team, the Coding Analyst develops coding education for clinical, billing, and hospital staff across inpatient and outpatient settings. Collaborating across chart assignment, diagnosis submission, and prebill review functions, this analyst resolves complex coding matters and keeps productivity and revenue projections on track.

What You'll Do

• Support and provide coding and compliance training to clinical personnel, billing, and other client staff.
• Establish effective communication with clinical and hospital staff to address documentation, coding, and reimbursement issues.
• Use knowledge of coding and compliance guidelines to identify potential billing or reimbursement issues.
• Participate in special audits and system administration as necessary.
• Perform diagnosis data submissions to clients, vendors, and internal stakeholders.
• Develop monthly productivity and revenue projections.
• Oversee chart assignment and monitor accounts on hold.
• Prepare data collection reports for leadership.
• Monitor diagnosis submission progress and audit diagnosis submission files to ensure accuracy.
• Review, analyze, and oversee pre-bill and post-bill reviews and pending accounts.
• Resolve workflow, systems, and complex matters related to coding.

Qualifications & Experience

• High school graduate or equivalent required, with an associate's or bachelor's degree in health information, nursing, or a related field, or formal coding classes completed and passed.
• AHIMA or AAPC credentials.
• 3 to 5 years of experience performing medical record coding in an acute care setting.
• Proficient in inpatient and/or outpatient diagnosis and procedure coding guidelines, including CPT/HCPCS code assignment and Evaluation and Management facility coding guidelines.
• Knowledge of MS-DRG, APR-DRG, and CPT classification and reimbursement structures.
• Proficient at writing AHIMA-compliant physician queries, and adept at comparing documentation, code assignment, and charge in the financial system for accuracy and completeness.
• Functional knowledge of facility EMR, encoder, CDI tool, and other support software.
• Ability to work in a sitting position, use a computer, answer the telephone, and lift to 25 pounds.