Description:
The Certified Professional Coder (CPC) – Primary Care (with Risk Code Review) is responsible for accurate and compliant coding of professional services, verification of demographic and insurance information, and timely resolution of front-end claim edits prior to submission. This role also includes reviewing encounters for accuracy of risk-related diagnosis codes to ensure proper documentation support in compliance with payer and CMS guidelines.
The coder supports Southeast Medical Group’s goals for revenue integrity, compliance, and operational efficiency through close collaboration with providers, front-end staff, and billing teams.
Requirements:
Essential Duties and Responsibilities
Coding and Charge Review
- Review provider documentation to assign accurate CPT, HCPCS, and ICD-10-CM codes for all primary care encounters, including preventive, chronic, and acute visits.
- Ensure all codes are supported by clinical documentation and comply with payer-specific rules and CMS guidelines.
- Apply appropriate modifiers and coding methodologies (E/M, time-based, and preventive care).
- Maintain current knowledge of industry coding updates, payer policies, and compliance standards.
Risk Code Review
- Review assigned encounters for the accuracy and completeness of risk-related diagnosis codes.
- Validate that documentation supports the risk codes assigned and identify potential gaps or discrepancies.
- Communicate with providers for clarification when documentation does not support submitted codes.
- Support organizational accuracy in risk coding without performing full risk adjustment or HCC coding functions.
Front-End and Pre-Billing Review
- Verify patient demographic and insurance information prior to submission to ensure correct payer routing.
- Review and clear front-end edits (eligibility errors, payer mismatches, invalid code combinations, or missing modifiers) within Medisys, Allscripts, and eClinicalWorks systems and clearinghouse platforms.
- Collaborate with front-office teams to correct registration and insurance entry errors in real time.
- Ensure all claims meet clean-claim submission standards to minimize payer rejections and processing delays.
Compliance and Quality Assurance
- Maintain coding accuracy standards of 95% or higher and meet turnaround goals for assigned encounters.
- Participate in internal and external audits, applying feedback for ongoing improvement.
- Adhere to all HIPAA regulations and SEMG confidentiality standards.
- Support education and training initiatives related to documentation, coding accuracy, and payer-specific requirements.
Team Collaboration and Communication
- Collaborate with providers and RCM leadership to ensure accurate, compliant documentation.
- Participate in required Microsoft Teams meetings for communication, training, and performance discussions.
- Promote teamwork, accountability, and a continuous-improvement culture within the RCM department.__
Qualifications
- Certification: Certified Professional Coder (CPC or equivalent AAPC credential required).
- Experience: Minimum 2 years of professional coding experience in Primary Care, Family Medicine, or Internal Medicine.
- Knowledge:
- CPT, HCPCS, ICD-10-CM, and E/M coding principles
- Risk code documentation and validation (non-HCC specific)
- Payer claim rules, modifier usage, and medical-necessity criteria
- Clearinghouse edit workflows and insurance eligibility processes
- Documentation compliance and audit readiness
- Technical Skills: Proficiency in Medisys, Allscripts, and eClinicalWorks systems; familiarity with clearinghouse platforms and Microsoft Office Suite.
- Soft Skills: Strong attention to detail, analytical and communication skills, and ability to multitask effectively in a remote environment.
Equipment and Workspace Requirements
- To ensure secure, compliant, and efficient performance in this role, coders must provide and maintain:
- A reliable computer system capable of running EMR and clearinghouse applications
- Two (2) monitors/screens for multi-tasking and coding efficiency
- A functioning webcam and microphone for Microsoft Teams meetings and training sessions
- A secure home office environment that ensures patient confidentiality and meets HIPAA standards (no public or shared workspace)
- A stable high-speed internet connection sufficient for EMR and Teams use
Work Environment
- Remote or office-based depending on assignment.
- Standard business hours with flexibility during audit or month-end periods.
- Requires participation in virtual team meetings, ongoing training, and performance reviews via Microsoft Teams.