Coding and Documentation Specialist
Coding and Documentation Specialist
- 515200
- Fort Worth, Texas, United States
- Staff
Title: Coding & Documentation Specialist
Employee Classification: Coding & Doc Specialist
Campus: University of North Texas Health at Fort Worth
Division: HSC-Health Systems
SubDivision-Department: HSC-Health Systems & Clinical Aff
Department: HSC-HSC Health Administration-335001
Job Location: Fort Worth
Salary: Salary Commensurate with Experience
FTE: 1.000000
Retirement Eligibility: TRS Eligible
About Us - Values Overview
Department Summary
UNT Health Clinical Practice Group is the academic clinical practice for UNT Health. Focused on improving health outcomes to build a healthier community. Clinical Practice Group primary and multispecialty care clinics are located on the UNT Health campus in Fort Worth. Our care teams extend to local hospitals, surgery centers, long-term and continuing care centers, and mobile and in-home care. The Clinical Practice Group’s interprofessional teams work collaboratively to achieve an optimized treatment plan tailored to the individual patient. Physicians, nurse practitioners, physician assistants, physical therapists, pharmacists, social workers, psychologists, specialized technicians, and nurses work together while intentionally integrating health care students, residents, and fellows to deliver care to our community.
Position Overview
The Coding and Documentation Specialist is responsible for reviewing clinical documentation and coding to ensure services are accurately documented, coded, and submitted in accordance with federal, state, payer, and organizational requirements. This position works closely with clinicians, Billing, and other departments to improve documentation quality, ensure complete charge capture, reduce coding-related denials, and support accurate and timely reimbursement.
The Coding and Documentation Specialist serves as a resource to clinicians regarding documentation and coding requirements and proactively identifies opportunities to improve documentation, coding accuracy, and revenue cycle performance.
Minimum Qualifications
Bachelor's degree or equivalent combination of education and experience.
Knowledge, Skills and Abilities
- Strong knowledge of ICD-10-CM, CPT, HCPCS, and modifier guidelines
- Knowledge of E/M coding and documentation requirements
- Understanding of Medicare, Medicaid, and commercial payer billing requirements
- Knowledge of coding compliance and medical necessity requirements
- Ability to interpret clinical documentation and determine whether reported codes are supported
- Strong analytical and problem-solving skills
- Excellent attention to detail
- Strong written and verbal communication skills
- Ability to communicate effectively and professionally with clinicians
- Ability to research complex coding and payer issues
- Ability to identify trends and recommend corrective actions
- Ability to manage multiple priorities and meet established deadlines
- Proficiency with electronic health record and practice management systems
- Ability to maintain confidentiality and appropriately handle protected health information
Preferred Qualifications
NextGen experience is a plus.
Required License/Registration/Certifications
CPC Certification Required
Job Duties
- Review clinical documentation and coding to ensure accuracy, completeness, medical necessity, and compliance with coding and payer guidelines.
- Ensure CPT, HCPCS, ICD-10-CM, modifiers, and charges are supported by the medical record.
- Identify and resolve missing documentation, signatures, diagnoses, charges, and other issues that delay billing.
- Work directly with clinicians to resolve documentation and coding concerns and provide ongoing education and guidance.
- Perform chart reviews and coding audits to identify trends, risks, and opportunities for improvement.
- Monitor pending and unbilled charges and follow up to support timely claim submission.
- Partner with Billing team to research and resolve coding-related claim edits and denials.
- Identify root causes of coding and documentation issues and recommend process improvements to prevent recurrence.
- Support accurate capture of applicable quality measures, including HEDIS, CMS Star Ratings, and payer incentive programs.
- Stay current on CPT, HCPCS, ICD-10-CM, CMS, Medicaid, Medicare, and payer-specific coding and documentation requirements
- Participate in Revenue Cycle, compliance, workflow improvement, and clinician education initiatives.
- Maintain confidentiality and comply with HIPAA, organizational policies, and coding compliance standards.
Physical Requirements
- Operating motor vehicles or heavy equipment.
- Repeating motions that may include the wrists, hands and/or fingers.
- Sedentary work that primarily involves sitting/standing.
- Moving about to accomplish tasks or moving from one worksite to another.
- Moving self in various positions to perform tasks in tight and confined spaces.
- Lifting and Moving objects up to 20 pounds.
- Communicating with others to exchange information.
Environmental Hazards
- No adverse environmental conditions expected.
Work Schedule
M-F 8-5
Driving University Vehicle
No
Security Sensitive
This is a Security Sensitive Position.
Special Instructions
Applicants must submit a minimum of two professional references as part of their application. If needed, additional references can be added after the application has been submitted.
Benefits
For information regarding our Benefits, click here.
EEO Statement
The University of North Texas System is firmly committed to equal opportunity and does not permit –and takes actions to prevent – discrimination, harassment (including sexual violence, domestic violence, dating violence and stalking), and retaliation on the basis of race, color, religion, national origin, sex, age, disability, genetic information, or veteran status in its application, employment practices, and facilities; nor permits race, color, national origin, religion, age, disability, veteran status, or sex discrimination and harassment in its admissions processes, and educational programs and activities. UNT System Administration promptly investigates complaints of discrimination, harassment, and related retaliation and takes remedial action when appropriate. System Administration also takes actions to prevent retaliation against individuals who oppose any form of harassment or discriminatory practice, file a charge or report, or testify, assist, or participate in a related investigation or proceeding.
