Coding Specialist I

“Sanitas is a global healthcare organization expanding across United States. Our services include primary care, urgent care, nutrition, lab, diagnostic, health care education and resources for our patients. We strive to attract professionals who believe in our mission, vision and are dedicated to the service of our patients and their families creating a memorable experience through compassion, respect, and kindness.”

Job Summary

The Coding Specialist I is responsible for coding all medical services procedures CPT and HCPCS codes, pharmaceutical supplies, patients’ ICD-10 diagnoses, signs, and symptoms when applicable, ensuring that all assigned ICD-10-CM codes are supported by proper clinical documentation. This position will be reporting directly to the Risk Adjustment Manager and the Risk Adjustment and Quality Sanitas USA director.

Essential Job Functions

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Utilizes ICD10 CPT and HCPCS codes for reporting diagnosis and procedures.
• Maintains performance and quality by conducting ongoing audits of physicians and mid-level providers’ medical records.
• Assigns all potential HEDIS-allowable codes for appropriate services to be captured.
• Ensures progress notes are coded accurately and to the highest level of specificity following established coding guidelines.
• Ability to abstract valid codes from hospital claims data and outpatient providers.
• Maintains productivity goals set by the department.
• Always maintains patient’s confidentiality, according to legal requirements and privacy laws.
• Follows established policies and procedures.
• Queries the physician for clarification and to obtain accurate and complete documentation as needed.
• Provides feedback to Supervisor regarding any coding issues.
• Supports ongoing review and query process to ensure that any amendment occurs in a timely and compliant manner.
• Attends departmental meetings as required.
• Cooperates with other personnel to achieve department objectives and maintain good employee relations, and interdepartmental objectives.
• Effectively manage special projects and other tasks as assigned.
• Ensure that any amendment occurs in a timely and compliant manner.
• Educates providers on HCC Coding and clinical documentation requirements related to risk adjustment.

Supervisory Responsibilities

This position has no supervisory responsibilities

Required Education

• High School Graduate, GED or equivalent training or experience required.

Required Experience

• Minimum 1 year of experience in Medical Coding (ICD-10, CPT, HCPC).

Required Licenses and Certifications

• Certified Professional Coder (CPC) and/or Certified Risk Adjustment Coder (CRC). CRC certification must be obtained within 1 year of hire.
• Required completion of an accredited certified coding specialist program.

Required Knowledge, Skills, and Abilities

• Ability to interpret, analyze and abstract data/documentation.
• Comprehensive knowledge of ICD-10-CM codes, Category II codes, COA measures, CMS documentation requirements, state and federal regulations including compliance and reimbursement and the impact of diagnosis coding on risk adjustment payment models.
• Intermediate level of proficiency in MS Office - Excel, PowerPoint, and Word. Ability to defend coding decisions to both internal and external audits.
• Strong organizational skills in multiple settings and the ability to exercise judgment and initiative.
• Ability to work in a continuously changing environment.

Preferred Qualifications

• Experience Risk Adjustment and HEDIS/Stars experience preferable.
• Certified Risk Adjustment Coder (CRC) preferred.
• Familiarity or experience with the Commercial and Medicare Risk Adjustment Payment Models is strongly preferred.

Financial Responsibilities

Budget Responsibilities

Languages

Travel

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

While performing the duties of this job the employee is regularly required to work standing up, walk, use hands to operate tools and equipment and must be able to exert regularly up to 10 pounds of force, frequently exert 30 pounds of force and occasionally exert 50 pounds of force to constantly perform the essential job functions. The employee will be frequently required to reach with hands and arms, bend, balance, kneel, crouch, crawl, push, and pull. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus.

Environmental Conditions

Inside: The employee is subject to environmental conditions, protection from weather conditions but not necessarily from temperature changes. The worker is subject to noise; there may be sufficient noise to cause the worker to shout in order to be heard above ambient noise level.

Physical/Environmental Activities

Please indicate with an X the frequency for the activities that apply to the essential functions of the job based on the chart below. Please select Not Required for physical demands that aren’t essential to job performance.

We are an Equal Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive, and equitable culture for our employees and communities.

This job description is not intended to be a complete list of all responsibilities, duties or skills required for the job and is subject to review and change at any time, with or without notice, in accordance with the needs of the company. Since no job description can detail all the duties and responsibilities that may be required from time to time in the performance of a job, duties and responsibilities that may be inherent in a job, reasonably required for its performance, or required due to the changing nature of the job shall also be considered part of the jobholder’s responsibility.