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Job Summary
Responsible for coding and abstracting procedural (CPT) and diagnosis codes (ICD-10) for physician services, reviewing physician documentation in the electronic medical record for completeness and accuracy to ensure proper code assignment, providing physician feedback of discrepancies/trends, resolving edits and denials, and releasing encounters for billing. Utilizes intermediate problem‑solving skills to address coding related tasks of detailed, medium complexity. Duties include procedural (CPT) and diagnosis (ICD-10) coding for all places of service, including, but not limited to ER, observation, inpatient, outpatient, ambulatory surgery, and other ancillary services. Responsible for reviewing, analyzing, and interpreting physician documentation, CPT and diagnosis coding, charge entry, coding claim edit, and coding denial management for coding related tasks.
Responsibilities
1. Review Clinical Documentation: Review physician or provider documentation to identify services rendered.
2. Assign Appropriate Medical Codes: Apply correct CPT , ICD10CM , and HCPCS codes for: E/M services, Diagnostic and procedural services, Facility or professional fees.
3. Ensure Compliance: Validate that documentation supports billed services; ensure coding follows Medicare/Medicaid regulations, CMS guidelines, and CPT documentation standards.
4. Resolve Coding Edits & Denials: Navigate EMR work queues (e.g., Epic) to address claim edits and charge review items; resolve coding–related denials to support accurate reimbursement.
5. Maintain Productivity & Quality Standards: Meet hourly productivity and accuracy standards set by enterprise coding teams.
6. Conduct Quality Audits: Perform audits within specialty areas to ensure coding accuracy and identify improvement opportunities.
7. Provide Education & Feedback: Educate providers on documentation and billing requirements; communicate trends in coding errors and denials.
8. Collaborate Across Teams: Work with billing departments, coding leadership, and clinicians to resolve billing or documentation concerns.
9. Enter and Validate Billing Data: Perform accurate charge entry and ensure all billing information is complete.
10. Develop Process Documentation: Create workflows, tip sheets, and written procedures to improve coding processes and train peers.
Core Competencies
Patient‑Centered Care – Demonstrates a commitment to delivering safe, compassionate, and high‑quality care that prioritizes the well‑being and satisfaction of patients and their families.
Integrity & Accountability – Acts ethically, maintains confidentiality, and accepts responsibility for actions, decisions, and outcomes.
Collaboration & Teamwork – Builds positive relationships, works effectively across departments, and supports colleagues to achieve shared goals.
Communication – Communicates clearly, respectfully, and effectively with patients, families, colleagues, and leadership.
Respect & Inclusion – Creates an inclusive environment by valuing diversity, treating others with dignity, and ensuring equitable care and opportunities for all.
Quality & Safety – Adheres to best practices, regulatory standards, and policies to ensure safe, reliable, and high‑quality outcomes.
Adaptability & Resilience – Responds effectively to change, remains flexible in dynamic situations, and demonstrates resilience under pressure.
Continuous Improvement – Seeks opportunities to improve processes, skills, and outcomes through innovation, learning, and feedback.
Leadership & Professionalism – Inspires, guides, and develops individuals and teams while modeling professionalism, fairness, and transparency.
Employee Experience Focus – Champions a supportive and engaging employee journey that enables staff to thrive and, in turn, deliver exceptional patient care.
Benefits
Health & Wellness: Medical, dental, vision, and prescription drug coverage.
Financial Security: Retirement savings plans with employer contributions, life insurance, and disability coverage.
Work‑Life Balance: Paid time off, holidays, and family leave benefits.
Career Growth: Tuition reimbursement, professional development programs, and opportunities for advancement.
Employee Support: Employee Assistance Program (EAP), wellness initiatives, and discounts on services.
Equal Opportunity Employer Statement
Grady Health System is proud to be an equal opportunity employer. We are committed to fostering a workforce where all employees feel valued, respected, and empowered to succeed. We prohibit discrimination and harassment of any kind based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other legally protected characteristic. Grady is dedicated to creating an accessible work environment and provides reasonable accommodations to qualified individuals with disabilities to ensure equitable opportunities for success.
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