Assign accurate and compliant ICD-10-CM diagnosis codes for inpatient encounters
Assign accurate and compliant ICD-10-PCS procedure codes
Review physician documentation for completeness and accuracy
Identify complications and comorbidities to ensure appropriate DRG assignment
Query physicians for documentation clarification when necessary
Ensure compliance with all applicable coding guidelines
Assign accurate CPT/HCPCS codes for outpatient services
Review encounter/charge data for completeness prior to claim submission
Prepare UB-04/837I institutional claims and CMS-1500/837P professional claims
Validate all coding assignments and charges against documentation
Submit claims electronically through designated clearinghouse or billing system
Monitor claim acceptance or rejection status
Review and analyze claim denials and rejections
Track denial trends and recommend process improvements
Maintain 95% patient billing accuracy rate
Document all coding decisions, queries, and claim corrections
Collaborate with clinical documentation improvement staff

Minimum 10 years of hospital medical billing and coding experience
5+ years of demonstrated experience in supervisory role of hospital setting highly desirable
Extensive experience with Emergency Room (ER) medical billing and coding
Required system experience with one or more of the following: CareVue, VistA, CPRS
Familiarity with hospital billing systems and clearinghouses
Electronic claims submission experience
Active certification as CPC or CCS preferred
Comprehensive knowledge of Medicare and Medicaid billing requirements
Proficiency in ICD-10-CM diagnosis and procedure coding
Proficiency in CPT/HCPCS coding
Experience with UB-04/837I institutional claim formats & CMS-1500/837P professional claim formats
Knowledge of APC assignment

Medical Billing, Coding and Denial Specialist

About this role