Coding Specialist

Meadows of Wickenburg Inc • Boynton Beach, FL

1d

About The Position

The Coding Specialist reviews patient medical records and translates diagnoses, treatments, and procedures into appropriate medical codes. The role ensures clinical documentation is coded accurately in accordance with applicable coding guidelines, regulatory requirements, and organizational standards, supporting accurate billing and reimbursement, medical record integrity, and compliance in a mental health and substance use treatment environment.

The position reviews records and documentation, assigns ICD-10-CM and applicable procedural codes, and identifies documentation that is incomplete, inconsistent, unclear, or ambiguous. The Coding Specialist communicates with clinical staff to seek clarification when appropriate, collaborates with clinical, billing, utilization review, and administrative departments, and escalates potential discrepancies to leadership. The role also uses EHR and billing technology, maintains coding records, stays current with relevant coding and payer requirements, and assists with audits, quality assurance, and compliance activities.

Requirements

• Strong grasp of medical terminology.
• Must have credentials such as CPC (Certified Professional Coder) or CCS (Certified Coding Specialist).
• Attention to detail and high accuracy when reading medical records to prevent financial or legal errors.
• Proficiency with electronic health record (EHR) and medical billing software.

Nice To Haves

• Experience coding in a psychiatric hospital, behavioral health facility, substance use treatment center, or similar healthcare setting.
• Experience with behavioral health and substance use disorder coding.
• Experience working with insurance claims, reimbursement, billing, or utilization review.
• Knowledge of Medicare, Medicaid, commercial insurance, and other applicable payer requirements.
• Experience participating in coding audits or compliance reviews.

Responsibilities

• Review patient medical records, clinical notes, assessments, treatment plans, and supporting documentation to identify diagnoses, treatments, and procedures requiring coding.
• Assign accurate ICD-10-CM and applicable procedural codes based on provider documentation and established coding guidelines.
• Apply current ICD-10 coding guidelines specific to mental health, behavioral health, substance use, and psychiatric hospitals or facilities.
• Ensure codes reflect documented diagnoses, services provided, and level of care.
• Review documentation for completeness, consistency, and accuracy before coding and billing.
• Identify missing, unclear, conflicting, or ambiguous documentation and communicate with physicians, nurses, and other clinical staff to obtain clarification when appropriate.
• Maintain accuracy and attention to detail to minimize billing, financial, compliance, and legal risks.
• Ensure coding practices comply with federal and state regulations, HIPAA requirements, payer requirements, and organizational policies.
• Maintain the confidentiality and security of protected health information (PHI).
• Collaborate with clinical, billing, utilization review, and administrative departments to resolve coding and documentation issues.
• Stay current with ICD-10 guideline changes, coding requirements, payer regulations, and applicable behavioral health and substance use treatment standards.
• Identify potential documentation and coding discrepancies and bring concerns to appropriate leadership for resolution.
• Use electronic health record (EHR) systems, medical billing software, and other technology needed for coding responsibilities.
• Assist with audits, quality assurance reviews, and compliance activities related to medical records and coding.
• Maintain organized and accurate coding records and documentation.
• Perform other duties and responsibilities as assigned by management.

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed