Cpc Medical Coder

A. Medical Coding Responsibilities

• Review outpatient clinical documentation, superbills, and encounter forms to assign accurate

  CPT

  ,

  ICD-10-CM

  ,

  HCPCS Level II

  , and

  J codes

  .
• Validate and calculate infusion and injection units based on

  dosage

  ,

  vial size

  , and

  HCPCS unit definitions

  .
• Apply appropriate

  modifiers

  (25, 59, 76, 91, JW, JZ, etc.) based on procedure type and payer guidance.
• Ensure compliance with

  CMS

  ,

  NCCI

  , and payer-specific billing rules.
• Maintain up-to-date understanding of

  Medicare LCDs

  ,

  MUEs

  ,

  bundling/unbundling edits

  , and

  CCI policies

  .
• Clarify any documentation discrepancies by coordinating directly with the provider or clinical team before claim submission.
• Review rejected or denied claims to identify root causes and recommend corrective actions related to coding or documentation.
• Support internal and external audits, ensuring all coded services are supported by clinical documentation.

B. Medical Billing Responsibilities

• Prepare, verify, and submit

  claims

  through clearinghouses or directly to payers following payer-specific rules.
• Review charges and ensure coding aligns with billed services and authorization requirements.
• Post

  payments

  , reconcile

  EOBs (Explanation of Benefits)

  , and record adjustments accurately in the billing system.
• Manage

  denials

  and

  rejections

  , correct identified errors, and resubmit claims promptly.
• Track unpaid or underpaid claims and perform follow-up with payers to ensure timely reimbursement.
• Handle

  patient billing inquiries

  , resolve statement issues, and explain balances when needed.
• Monitor

  payer trends

  ,

  claim turnaround times

  , and

  aging reports

  to highlight revenue risks or systemic issues.
• Collaborate with the coding, compliance, and operations teams to ensure end-to-end billing accuracy and revenue integrity.
• Maintain accurate documentation of all billing actions and communications for audit readiness.

Compliance and Confidentiality

• Adhere strictly to

  HIPAA

  and

  HITECH

  privacy and security requirements.
• Ensure all activities comply with

  federal, state, and payer regulations

  .
• Participate in compliance training and maintain awareness of coding and billing policy updates.

Performance and Quality Expectations

• Maintain

  coding accuracy 95%

  and

  billing clean claim rate 98%

  .
• Ensure all claims are submitted within agreed timelines.
• Proactively identify and correct recurring claim or documentation issues.
• Support continuous improvement of revenue cycle workflows and best practices.

Preferred Background and Skills

• Minimum 23 years of experience in

  outpatient coding and billing

  .
• Strong understanding of

  Medicare, Medicaid

  , and

  commercial payer

  rules.
• Experience in

  Internal Medicine, Cardiology, Rheumatology, or Oncology

  preferred.
• Familiarity with

  EHR and practice management systems

  .
• Knowledge of

  revenue integrity

  ,

  audit processes

  , and

  drug wastage documentation

  .
• Strong analytical, problem-solving, and communication skills.

Deliverables and Reporting

• Daily: Charge review and claim submission logs.
• Weekly: Denial and payment posting summary.
• Monthly: Coding and billing accuracy reports, denial trends, and AR aging summary.
• Periodic: Participation in compliance or internal audit reviews as assigned.