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Professional Coding and Documentation Improvement Specialist
HCA Healthcare. Facilitate compliant physician coding and documentation for accurate assignment of diagnosis, Evaluation and Management (E&M), and Current Procedural Terminology (CPT) codes .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in physician coding and documentation, ensuring compliance with industry guidelines and accurate assignment of diagnosis, CPT, and E&M codes. Proficient in developing and delivering educational materials to enhance documentation practices and support coding accuracy.
Highest-signal resume keywords
Certified Professional Coder (CPC)ICD-10-CM Coding ExperienceCPT Coding ExperienceTwo Years’ Experience In Professional Coding RoleKnowledge Of Industry Guidelines And Laws
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Physician CodingEvaluation And Management (E&M) CodingCurrent Procedural Terminology (CPT) CodingICD-10-CM CodingHCPCS CodingMedical TerminologyAnatomy And Physiology KnowledgePathophysiology KnowledgeResearch And Analysis SkillsDocumentation Improvement
Soft Skills
Excellent Verbal Communication SkillsExcellent Written Communication SkillsAbility To Work CollaborativelyAbility To Work IndependentlyTeamwork And Collaboration
Tools & Technologies
Microsoft OutlookMicrosoft WordMicrosoft ExcelMicrosoft PowerPointEMR Systems
Certifications & Qualifications
Certified Professional Coder (CPC)Certified Coding Specialist-Physician-based (CCS-P)Physician Coding And Training Certification
Industry Keywords
ComplianceDocumentation StandardsMedical NecessityReimbursementCoding EducationDocumentation Improvement InitiativesRevenue CycleMedical Record DocumentationCoding GuidelinesHealthcare Regulations
About the role
Key responsibilities & impact- Facilitate compliant physician coding and documentation for accurate assignment of diagnosis, Evaluation and Management (E&M), and Current Procedural Terminology (CPT) codes
- Monitor medical record documentation content to ensure compliance with industry guidelines, laws, and regulations
- Provide provider feedback and education on proper documentation to support code-level selections
- Identify and report recurring coding and documentation improvement areas to leadership
- Review and respond to requests for coding and documentation education
- Support proactive documentation improvement initiatives within Capital Health Medical Group
- Review medical record documentation for accurate assignment and support of diagnosis, CPT, and E&M codes
- Monitor provider-selected E&M codes to ensure documentation supports medical necessity, code specificity, and compliance
- Develop and deliver education materials promoting clear, accurate, and complete documentation
- Meet or exceed departmental accuracy and productivity standards
- Communicate documentation opportunities and monitoring results clearly and constructively to providers
- Foster teamwork and collaboration
- Attend hospital and medical staff meetings regarding documentation issues
- Partner with revenue cycle teams to resolve complex coding-related issues
- Support professional coders with pre-bill edits as needed
- Facilitate changes required to capture needed documentation on EMR templates
- Assist in appeals resulting from third-party reviews
- Act as a subject matter expert for professional coding and documentation improvement questions
- Perform other duties as assigned
Requirements
What you’ll need- High School Diploma or equivalent
- Certified Professional Coder (CPC) or Certified Coding Specialist-Physician-based (CCS-P) required
- Physician coding and Training certification
- Two years’ experience in professional coding role
- ICD-10-CM, CPT, CM, and HCPCS coding experience
- Excellent verbal and written communication skills
- Knowledge of pathophysiology and disease processes
- Strong knowledge of industry guidelines and laws for physician coding and reimbursement
- Research and analysis skills
- Proficient with Microsoft Outlook, Word, Excel, and PowerPoint
- Medical Terminology, Anatomy and Physiology, or Pathophysiology knowledge
- Ability to develop, implement, deliver, and assess coding education plans using a variety of methods
- Ability to work using multiple EMR systems
- Ability to work collaboratively and independently
- Candidates must be located in New Jersey, Pennsylvania, or Alabama
Benefits
Comp & perks- Medical Plan
- Prescription drug coverage & In-House Employee Pharmacy
- Dental Plan
- Vision Plan
- Flexible Spending Account (FSA), including Healthcare FSA and Dependent Care FSA
- Retirement Savings and Investment Plan
- Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance
- Supplemental Group Term Life & Accidental Death & Dismemberment Insurance
- Disability Benefits – Long Term Disability (LTD)
- Disability Benefits – Short Term Disability (STD)
- Employee Assistance Program
- Commuter Transit
- Commuter Parking
- Supplemental Life Insurance, including Voluntary Life Spouse, Voluntary Life Employee, and Voluntary Life Child
- Voluntary Legal Services
- Voluntary Accident, Critical Illness and Hospital Indemnity Insurance
- Voluntary Identity Theft Insurance
- Voluntary Pet Insurance
- Paid Time-Off Program
- Bonus and/or incentive eligibility determined by role and level