Coding Specialist

Meadows of Wickenburg•Boynton Beach, FL

18h

About The Position

The Coding Specialist reviews patient medical records and accurately translates documented diagnoses, treatments, and procedures into appropriate universal alphanumeric medical codes. The position supports accurate billing and reimbursement, medical record integrity, and compliance in a mental health and substance use treatment environment. Coding must follow applicable guidelines, regulatory requirements, payer requirements, and organizational standards. The specialist works with clinical, billing, utilization review, and administrative departments to resolve coding and documentation issues, maintains the confidentiality and security of protected health information, and stays current with coding and regulatory changes. The role also supports audits, quality assurance reviews, and compliance activities related to medical records and coding.

Requirements

Strong grasp of medical terminology.
Must hold a coding credential such as CPC (Certified Professional Coder) or CCS (Certified Coding Specialist).
High attention to detail and 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 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.
Accuracy and attention to detail.
Medical terminology and coding knowledge.
Knowledge of behavioral health and substance use documentation.
Confidentiality and professionalism.
Effective communication.
Critical thinking and problem-solving.
Organization and time management.
Regulatory and compliance awareness.
Teamwork and collaboration.

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 guidelines.
Apply current ICD-10 coding guidelines relevant to mental health, behavioral health, substance use, and psychiatric hospitals or facilities.
Ensure codes accurately 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 seek clarification from physicians, nurses, and other clinical staff when appropriate.
Maintain accuracy and attention to detail to minimize billing, financial, compliance, and legal risks.
Ensure coding practices comply with applicable federal and state regulations, HIPAA requirements, payer requirements, and organizational policies.
Maintain confidentiality and security of protected health information.
Collaborate with clinical, billing, utilization review, and administrative departments to resolve coding and documentation issues.
Stay current with ICD-10 guidelines, 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 systems, medical billing software, and other necessary technology.
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.