Coding Specialist Job Description

Without accurate code assignment, hospitals, clinics, and outpatient facilities submit claims that trigger denials, compliance flags, and lost reimbursement. The Coding Specialist prevents that by translating physician documentation into ICD-10-CM, CPT, and HCPCS codes that satisfy Correct Coding Initiative edits and payer-specific billing rules across care settings. Errors here ripple into the revenue cycle. The role sits between clinical documentation and the billing office, closing gaps that generic administrative staff cannot resolve, particularly under Medicare Advantage risk-adjustment models and hospital DRG reimbursement requirements that vary by payer contract.

Coding Specialists in healthcare are accountable for converting clinical documentation into compliant ICD-10-CM, CPT, and HCPCS codes that support accurate billing and defensible audits. Working within the Health Information Management or Revenue Cycle department, the Coding Specialist partners with providers and billing staff to resolve documentation gaps before claims go out.

Career Impact: Earning recognized credentials such as CPC or CCS signals mastery employers weight heavily when filling this seat, often ahead of general administrative experience.

Business Impact: Correct code assignment keeps denial rates down and protects reimbursement timelines that facilities and providers both depend on.

Growth Opportunity: Consistent accuracy scores open a path toward auditing, risk adjustment, coding leadership, or compliance-focused specialist roles.

• Assign ICD-10-CM, CPT, and HCPCS codes to physician, outpatient, and hospital facility documentation to support accurate claim submission.
• Review medical records, operative reports, and diagnostic progress notes to identify missing or unclear documentation before code assignment.
• Resolve coding edits and billing denials by researching payer guidelines, insurer coverage determinations, and Correct Coding Initiative updates.
• Collaborate with providers, billing staff, and coding leadership regularly to clarify ambiguous documentation and confirm code accuracy.
• Monitor individual productivity and accuracy scores weekly against departmental coding quality and turnaround targets.
• Maintain current knowledge of payer-specific billing rules, seasonal regulatory updates, and coding convention changes across specialties.
• Support internal chart audits and new coder education by reviewing peer work for annual compliance and accuracy.
• Document coding decisions and provider query responses daily to preserve a defensible audit trail for each encounter.

• Bachelor's degree in health information management, health sciences, or a related field, or equivalent work experience.
• 1 or more years of medical coding experience, with exposure to ICD-10-CM, CPT, and HCPCS.
• Active coding certification, such as CPC, CCS, or equivalent, or eligibility to obtain one within a defined window.
• Working knowledge of payer-specific billing guidelines, Correct Coding Initiative edits, and Local Coverage Determinations.
• Ability to interpret physician, operative, and diagnostic documentation across specialties for accurate code sequencing.
• Strong attention to detail and accuracy under productivity-based performance and quality metrics for daily work.
• Effective written and verbal communication skills for resolving provider queries and denial follow-up.
• Familiarity with electronic health record and practice management systems used for chart review and code entry.

• Experience with risk adjustment or HCC coding models, including Medicare Advantage documentation, coding, and validation requirements.
• Prior involvement in denial appeals or payer audit response, including RAC, MAC, or FI record requests.
• Background in a specialty coding area such as emergency, surgical, ambulatory, or risk adjustment documentation.
• Exposure to inpatient DRG assignment or hospital-based coding workflows and internal quality control audits.

• Coding accuracy rate, reflecting how closely assigned codes match documentation and payer rules.
• Charts coded per hour, measuring throughput against departmental productivity targets.
• Claim denial rate tied to coding errors, showing how well codes withstand payer review.
• Query turnaround time, measuring how quickly documentation clarifications are resolved with providers.
• Quality audit score, reflecting how consistently coding decisions pass internal chart review.
• Typical tools: office software (commonly Microsoft Excel or Word).

• Base Salary Range: $42,000 to $58,000 per year, depending on certification and experience level
• Bonus: Occasional annual bonus of 2 to 5 percent tied to individual productivity and accuracy metrics
• Equity: Not typically offered for this role
• Health Benefits: Medical, dental, and vision coverage, often with employer premium contributions
• PTO: Typically 10 to 20 days annually, increasing with tenure
• Common Perks: Remote or hybrid scheduling, tuition assistance, and continuing education support for certification renewal

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

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

The Coding Specialist owns accurate CPT, HCPCS, and diagnosis code assignment for ambulatory, clinic, and hospital outpatient encounters, including urgent care and emergency services. Reporting to coding leadership, the Coding Specialist applies chart auditing knowledge and payer billing guidelines to keep code assignment consistent with clinical documentation.

Key Responsibilities

• Review and audit patient medical records, applying knowledge of coding guidelines, anatomy and physiology, and pharmacology to select diagnostic and procedural codes for clinic, hospital outpatient, and ancillary encounters.
• Apply appropriate CPT, HCPCS, and diagnosis codes into EPIC for billing, research, planning, and quality improvement.
• Apply billing guidelines including new versus established patients, modifiers, units, teaching physician guidelines, surgical coding, global period, and shared visits.
• Provide feedback on coding changes and use standard query processes to contact providers for clarification and additional documentation.
• Assist with coding inquiries for internal and external customers, with attention to appropriate CPT codes.
• Assist with internal coding audits as requested.
• Answer the telephone, respond to inquiries, and route calls to appropriate staff as needed.
• Assist with staff and student training, including job shadowing applicants.
• Complete annual department job-specific competencies.

Minimum Qualifications

• High school diploma or equivalent.
• Certified Professional Coder - Apprentice (CPC-A), Certified Coding Associate (CCA), Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Coding Specialist-Physician Based (CCS-P), Registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT).
• 1 or more years of experience in a healthcare facility, health care business office, or equivalent education.
• 1 year of professional medical or hospital coding experience preferred, with a Health Information Technology associate degree accepted in place of experience.
• Working knowledge of chart auditing, including CPT, HCPCS, and ICD-10-CM coding guidelines consistent with standard coding practices.
• Ability to communicate professionally with providers to resolve documentation and coding queries.

Embedded within the coding and revenue cycle department, the Coding Specialist delivers accurate charge review, coding edit resolution, and denial trend research across daily assigned work queues and payer accounts. Working closely with coding leadership, the Coding Specialist maintains compliance with corporate policy, payer guidelines, and Correct Coding Initiative updates to protect reimbursement and productivity targets.

Core Functions

• Code claims directly from the medical record or operative report according to coding guidelines.
• Complete charge review work queues accurately and on time as assigned.
• Assist with tracking and trending coding issues and research denied claims.
• Maintain compliance with corporate and departmental policies, quality improvement programs, and productivity expectations.
• Track individual quality and productivity performance metrics in daily duties as set by coding leadership.
• Stay current on payer guidelines, Correct Coding Initiative edits, and Local and National Coverage Determinations for coding accuracy.
• Participate in educational activities, including coding meetings, to stay informed on coding and compliance topics.
• Communicate professionally with physicians, management, and peers.

Required Qualifications

• High school diploma or GED required, with a two-year associate degree preferred.
• AAPC or AHIMA coding certification, such as CPC-A, CPC, or CCS-P, required.
• 1 or more years of coding experience, or successful completion of a coding curriculum.
• Knowledge of or previous experience in physician procedural coding.
• Knowledge of medical terminology, ICD-10, CPT, and HCPCS.
• Proficiency with PC applications, coding software tools, and EPIC.
• Excellent organizational, communication, time management, and problem-solving skills, with the ability to multitask and prioritize competing timelines.

Reporting to coding leadership, the Coding Specialist shapes accurate diagnosis reporting by processing PQRI reports, resolving coding edits, and preparing unable-to-code charts for review, meeting a 95 percent quality standard. Partnering with reimbursement and client teams, the Coding Specialist reduces billing denials and keeps top diagnosis validation current for assigned services.

Primary Duties

• Process daily PQRI reports by reviewing charts and adding PQRI codes and diagnoses.
• Process daily reports to analyze and fix coding edits prior to billing and reduce denials.
• Process daily diagnosis reports to validate the top four diagnoses.
• Assign ICD-9 diagnosis codes to assigned service charts.
• Review denials to correct or justify CPT and diagnosis coding.
• Support the coding process by performing validation projects as needed.
• Search medical records online for supporting information.
• Assign cases to coders and prepare unable-to-code charts for review.
• Send unable-to-code lists and charts to clients.

Skills & Qualifications

• Bachelor's degree, certification, or equivalent combination of education and experience required.
• Prior coding experience or certification credentials required.
• 1 to 2 years of related experience preferred, including working knowledge of ED billing and prior experience with ICD-9 and CPT coding.
• Experience with interventional radiology coding or a multi-specialty background a plus.
• Prior MS Office experience, including proficiency with Excel and Word, and internet software experience required.
• Ability to access and accurately enter information using word processing and internet software, including Laserfiche.
• Ability to work with meticulous attention to detail and complete reports the same day.
• Excellent communication skills, with the ability to read, interpret, and write routine reports and correspondence.
• Ability to apply common-sense understanding to carry out written, oral, or diagrammed instructions and resolve problems involving several concrete variables.
• Specific vision and physical abilities required, including close vision, prolonged sitting, and occasional walking and reaching.

Sitting at the intersection of clinical documentation and risk adjustment reporting, the Coding Specialist leads accurate ICD-10 and CPT code assignment for HCC-driven physician encounters under governmental coding regulations. Operating across specialist notes, imaging reports, and lab documentation, the Coding Specialist keeps diagnosis sequencing consistent with payor analysis projects and organizational compliance and confidentiality standards.

Duties

• Code encounters accurately according to compliance guidelines, assigning ICD-10 and CPT codes from physician documentation.
• Review specialist notes, imaging reports, and lab reports to support providers' risk adjustment and HCC coding.
• Maintain working knowledge of CPT and ICD-10 coding principles, governmental regulations, and third-party billing requirements.
• Communicate coding trends or patterns affecting workflows to the coding supervisor.
• Sequence diagnoses and procedures according to coding guidelines.
• Support special projects such as payor analysis reports as needed.
• Maintain work operations by following organizational standards, policies, and procedures.
• Comply with federal and local confidentiality laws, including HIPAA, to ensure patient privacy.

Requirements

• Current Certified Professional Coder (CPC) certification required.
• 3 or more years of experience as a Certified Professional Coder.
• Expertise in the ICD-10 and CPT coding systems.
• In-depth knowledge of documentation and coding for risk adjustment.
• Capacity to work both independently and as part of a team, with the ability to self-direct.
• Ability to multitask and operate under pressure, with the capability to think critically and solve problems.
• Excellent interpersonal and communication skills, with the ability to work effectively with patients, providers, and vendors.
• Skilled in the use of technology and software programs, including electronic medical records and Microsoft Office applications.

A key member of the coding and revenue cycle team, the Coding Specialist builds accurate CPT and ICD coding across surgical, ER, and consultation encounters routed from multiple report types. Collaborating across coding vendors and clinical documentation staff, the Coding Specialist supports appeals for denied surgical and procedural claims.

Functions

• Maintain a comprehensive understanding of coding rules and guidelines to support internal communication and policy.
• Maintain a thorough understanding of anatomy, physiology, medical terminology, and disease processes to apply ICD-9/ICD-10 and CPT-4 guidelines.
• Facilitate accurate clinical and operative documentation through interaction with physicians, advanced practice providers, and clinical staff.
• Route operative, procedure, ER, and consultation reports to internal or external coding vendors.
• Coordinate with the workflow specialist to ensure external operative notes and visits are received.
• Create encounters for emergency room, consultation, and other non-scheduled visits and surgeries.
• Code from final surgical or procedural reports and file charges to appropriate insurance carriers, or review coding for external vendors.
• Educate internal staff on clinical documentation needs, guideline changes, and reimbursement issues.
• Assist with planning, education, and training for CPT and ICD-10 code assignment.
• Support the coding lead or revenue cycle supervisor in identifying documentation issues to optimize compliance and revenue.
• Assist with the appeals process for insurance denials of surgical or procedural services.

Experience & Qualifications

• Credentialed coder certificate, such as CPC, CCS, CPMA, CCDS, RHIT, or RHIA, preferred.
• Experience with electronic medical or health records systems preferred.
• Proficiency with Microsoft Excel and Word preferred.
• Ability to make sound judgments and identify appropriate exceptions when needed.
• Confidence and ability to work closely with clinical staff and physicians.
• Excellent interpersonal skills for building effective partnerships with internal departments.

Accurate national and provincial ambulatory data reporting depends on the Coding Specialist, who owns ICD-10-CA and CCI code assignment for outpatient, emergency, and day surgery encounters. Based within the health information management team, the Coding Specialist supports NACRS submission timelines, ongoing coding data quality audits, and continuing education requirements.

Accountabilities

• Collect predefined data sets and apply ICD-10-CA/CCI classification methodology for statistical and clinical data.
• Abstract data into health data management software and coding tools.
• Code and abstract for the National Ambulatory Care Reporting System.
• Analyze patient health records thoroughly to reflect resource utilization accurately.
• Assign diagnostic and intervention codes following national 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 for ongoing self-development.
• Participate on committees and working groups as required.

Technical Qualifications

• Graduate of a recognized health information management program.
• Certification with a recognized health information management college, in good standing, required.
• Proven knowledge of current abstracting methods and national coding standards required.
• 2 to 3 years of previous coding and abstracting experience preferred.
• Proven knowledge of ICD-10-CA/CCI coding nomenclature.
• Knowledge of inpatient and ambulatory grouping and weighting methodologies preferred.
• Knowledge of health system funding reform methodology and quality-based procedures preferred.
• Experience with specialized health records and hospital applications, including clinical information systems and abstracting tools.
• Computer proficiency in a Windows environment and Microsoft Office applications.
• Strong judgment and decision-making skills, with excellent teamwork, interpersonal, and communication abilities.
• Ability to work independently and collaboratively within a team environment, with a satisfactory attendance record.

As the Coding Specialist, this role delivers charge review accuracy, chart audit support, and provider coding education across daily billing and compliance review cycles. The coding and compliance department relies on this work to keep denial rates low, missing charges resolved, and provider documentation audit-ready.

Activities

• Participate in provider and employee coding education.
• Conduct daily review of charges to ensure coding compliance with national and payer-specific guidelines.
• Assist with chart audits to ensure services are coded correctly per federal, state, and payer requirements.
• Provide coding instructions and input on coding changes following federal, state, and payer reimbursement requirements.
• Review hospital and invoice services for correct coding, including data entry and reconciliation of daily batches.
• Support compliance with the organizational code of ethics and compliance plans.
• Maintain the daily missing charge process to resolve missing charges without lost revenue.
• Train and coach providers on documentation, coding, and reimbursement requirements, including annual quality assurance reviews.
• Assist billing specialists with denials based on codes and modifiers.

Position Requirements

• Certification as a coding specialist, such as CPC, required.
• Associate degree, or a combination of relevant education and experience, required.
• 1 to 2 years of professional coding experience required.
• Experience in coding, chart auditing, and provider education preferred.
• Previous billing experience preferred.
• Excellent customer service, written, and oral communication skills.
• Knowledge of chart auditing practices and correct coding guidelines.
• Knowledge of patient billing policies and procedures.
• Ability to work independently and as part of a team with minimal supervision, effectively following oral and written instructions.
• Active engagement in ongoing professional development and continuing education.

Coding Specialist shapes accurate HCC and ICD-10 risk adjustment coding across provider notes, imaging reports, and lab chart reviews entered into the electronic health record. The work directly supports timely claim filing, resolved provider discrepancies, and Medicare Advantage risk score accuracy within a defined 48- to 72-hour turnaround window.

Operational Focus

• Review provider notes to abstract, assign, and enter valid ICD-10 and HCC codes into the electronic health record platform.
• Perform medical chart reviews to identify and correct missed or erroneous HCC codes per coding requirements.
• Work with providers to gain clarification or resolve discrepancies identified during the coding process.
• Enter charges into the practice management system.
• File electronic claims within 48 to 72 hours of entry.

Knowledge, Skills & Abilities

• Coding certification required, such as CPC, CRC, or CCSP.
• 5 or more years of medical coding experience, with a minimum of 2 years as a risk adjustment coder in a health plan.
• Demonstrated proficiency in ICD-10-HCC coding guidelines for chronic conditions.
• Required knowledge and understanding of Medicare Advantage guidelines.
• Proficient in medical terminology, anatomy and physiology, pharmacology, and electronic health record systems.
• Proficiency in Microsoft Excel and Word.
• Strong analytical and problem-solving skills, with a proven ability to meet deadlines.
• Solid organizational skills and attention to detail, with the ability to maintain confidentiality of patient information.

The Coding Specialist produces timely, accurate responses to payor and auditor requests for patient medical records, including RAC, MAC, and FI appeals. Reporting to health information management leadership, the Coding Specialist coordinates system-wide with facilities and outside consultants to manage the coding denial appeals process.

Key Deliverables

• Track and monitor responses to external payor and auditor requests for patient medical records, including timely appeals.
• Act as liaison between facilities and external requestors to ensure complete medical records are received on time.
• Coordinate with external consultants and outside counsel on higher-level RAC determination appeals.
• Manage the denial management process for coding-related denials, evaluating claims and determining the need for appeal.
• Apply relevant coding and billing guidelines, working with facilities to determine appeal eligibility.
• Track, monitor, and report RAC coding-related recoupments, payments, and the effectiveness of the appeal process.
• Identify coding trends and claim review patterns across external payors and auditors.
• Monitor external payor and auditor strategies to keep system and facility approaches current.
• Coordinate focus areas for audits and education to address coding and billing regulations and prevent denials.

Education & Experience

• Bachelor's degree in health information management, or equivalent, with ongoing continuing education.
• Certified Coding Specialist (CCS), Certified Professional Coder (CPC), Certified Coding Specialist-Physician (CCS-P), Registered Health Information Technologist (RHIT), or Registered Health Information Administrator (RHIA) credential required.
• 5 or more years of health care coding experience required, with proficiency in hospital or multi-specialty coding.
• Thorough knowledge of ICD, DRG, and CPT coding principles and recommended coding competencies.
• In-depth knowledge of medical terminology, anatomy and physiology, clinical record content, and reimbursement guidelines across service lines.
• Extensive critical and analytical thinking skills required.
• Ability to organize workload to meet deadlines while maintaining confidentiality of work information.
• Ability to research, interpret, and develop recommendations, with excellent written and oral communication skills.
• Familiarity with the Medicare Prospective Payment System, coding databases, and common office and electronic medical records software.

Embedded within a remote coding team supporting multiple client accounts, the Coding Specialist develops accurate daily ICD-10, CPT, and HCPCS coding across emergency room and outpatient encounters. Working closely with coding leadership and clients, the Coding Specialist maintains a 95 percent quality and productivity standard while using current coding reference materials on every assigned case.

Areas of Ownership

• Provide coding services remotely to support assigned clients.
• Analyze medical records to determine appropriate sequencing and assignment of ICD-10, CPT, and HCPCS codes.
• Recognize critical care cases by patient acuity.
• Code surgical procedures typical of an emergency room setting to capture appropriate revenue.
• Apply ICD-10-CM diagnosis codes to the highest level of specificity available.
• Interpret coding guidelines for accurate code assignment and identify documentation gaps affecting reimbursement.
• Maintain quality and productivity standards in daily coding work.
• Communicate with clients professionally to support an effective working relationship.
• Assist leadership or the lead coding specialist with reports as needed.

Background & Experience

• Certification through AAPC (CPC or COC) or AHIMA (CCS or CCS-P) required; CCS certification preferred.
• 2 or more years of coding experience required.
• Advanced working knowledge of systems such as electronic medical records and billing platforms.
• Proficiency in Microsoft Excel and Outlook, including basic formulas, pivot tables, and email and calendar management.
• Access to current coding reference materials, such as CPT and ICD-10-CM manuals.
• Ability to maintain an accuracy and quality score of 95 percent or higher.
• Ability to communicate effectively and professionally, both verbally and in writing.
• Ability to coordinate, analyze, observe, make decisions, and meet deadlines.

Reporting to coding leadership, the Coding Specialist refines complex encounter coding accuracy across bedside procedures, diagnostic tests, and physician professional services, meeting a 95 percent quality standard. Partnering with revenue cycle and account inquiry staff, the Coding Specialist resolves documentation gaps that affect claim accuracy and denial appeals.

Role Responsibilities

• Assign codes to diagnoses and procedures using all available documentation, including bedside procedures and diagnostic tests.
• Ensure codes are sequenced correctly per government and insurance regulations, meeting a 95 percent accuracy standard.
• Serve as the key contact for revenue cycle and account inquiry staff in obtaining documentation.
• Confirm charges are captured by reconciling procedure schedules, logs, and clinical system reports.
• Follow up with providers on insufficient or unclear documentation.
• Identify documentation, billing, and coding opportunities for physicians and staff.
• Correct incorrect billed services, add missing unbilled services, and update CPT and ICD-10 codes and modifiers.
• Provide code and modifier information to support denial appeals.
• Request medical record notes and additional documentation from facilities or the electronic medical record system.
• Contact providers for peer-to-peer reviews.

Professional Experience

• High school diploma required.
• Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification required.
• 2 or more years of experience as a coder.
• Solid understanding of billing, coding, and electronic medical record systems.
• Excellent written, verbal, and analytical communication skills.
• Excellent computer skills, with familiarity with Microsoft Office and collaboration tools across various operating systems.
• Excellent organizational skills, reflecting the ability to prioritize multiple tasks with strong attention to detail.
• Demonstrated commitment to promoting a positive, team-oriented work environment focused on quality.

Sitting at the intersection of hospital coding operations, quality control, and network-wide discharge data reporting, the Coding Specialist oversees daily DRG assignment accuracy across inpatient and outpatient charts. Operating across the coding hotline, STAT coding, and interim billing functions, the Coding Specialist keeps billing deadlines, coder training, case-mix reviews, and audit standards on track.

Job Functions

• Abstract, sequence, and assign diagnosis and procedure codes per coding conventions and discharge data set definitions.
• Assign diagnosis-related groups using specialized coding software.
• Perform specialized coding and assist with billing rejection audits and case-mix questions.
• Maintain up-to-date knowledge of regulatory and compliance issues related to coding, documentation, and billing.
• Follow up on outstanding, uncoded, and incomplete charts.
• Perform periodic quality control audits of coding work.
• Support coder education and training, reviewing new coders' work for quality and accuracy.
• Provide leadership in decision-making and prioritization in the absence of the area supervisor.
• Maintain awareness of coding unit activities and goals to meet billing deadlines.
• Respond to outpatient clinic requests for diagnosis codes.
• Support the coding hotline, STAT coding, and interim billing as needed.
• Assist researchers in identifying cases by diagnosis or procedure codes.

Required Qualifications

• Associate degree in medical records or a related field, or 2 years of occupationally specific education, required, with 4 years of hospital-based coding experience.
• Current certification through AHIMA as a Certified Coding Specialist (CCS) or Registered Health Information Technician (RHIT) required.
• Ability to organize and abstract health data for database entry and understand healthcare data usage.
• Knowledge of health records, computer systems, Microsoft applications, and data integrity processing techniques.
• Knowledge of medical terminology, anatomy, physiology, pathophysiology, and DRG and APR-DRG grouping programs.
• Achieve a minimum 80 percent accuracy rate on the pre-employment coding assessment.
• Highly detail-oriented, with strong organizational, interpersonal, and communication skills and the ability to remain focused.
• Analytical skills to resolve problems using scientific, mathematical, technical, or clinical reasoning.
• Knowledge of HIPAA rules and regulations regarding patient information and confidentiality.