Coding and Documentation Specialist

University of North Texas System • Fort Worth, TX

1d • Onsite

About The Position

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.

Requirements

• Bachelor's degree or equivalent combination of education and experience.
• 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
• CPC Certification Required

Nice To Haves

• NextGen experience is a plus.

Responsibilities

• 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.

Benefits

• Salary Commensurate with Experience
• TRS Eligible
• Benefits information available via provided link

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level