What are the responsibilities and job description for the Coding Documentation Improvement Specialist position at WOMENS HEALTHCARE ASSOCIATES LLC?
At WHA, we're a team, passionate about humanizing healthcare. We're inspired by the diverse stories, strength and resilience of our patients and the unique choices they make in pursuing health for themselves and their families. We envision a world where every person has the opportunity to achieve their optimal health and we're here to support that journey with personalized, culturally competent care and knowledge.
The Coding Documentation Improvement Specialist focuses on ensuring that medical records and clinical documentation accurately reflect the care provided to patients. The primary purpose of the position is to enhance the quality and completeness of medical documentation to support accurate coding, billing, and compliance with regulatory requirements.
ESSENTIAL JOB DUTIES
• Review medical records to identify documentation gaps, inconsistencies, and opportunities for improvement.
• Ensure provider documentation supports accurate code assignment for ICD-10, CPT, HCPCS coding systems.
• Collaborate with coding staff to clarify diagnoses, procedures, and services to enhance claim accuracy and minimize denials.
• Educate providers and clinical staff on best practices for documentation.
• Deliver feedback to providers on documentation deficiencies and offer guidance for improvement.
• Conduct training sessions on coding changes, payer requirements, and regulatory updates.
• Perform prospective and retrospective medical record reviews to assess documentation quality.
• Identify trends in documentation deficiencies and implement corrective action plans.
• Assist in responding to external and internal coding audits and compliance reviews.
• Ensure documentation aligns with CMS, Joint Commission, and payer regulations.
• Stay updated on industry changes, including CPT and ICD-10 updates.
• Support compliance initiatives by maintaining documentation integrity and reducing audit risks.
• Work closely with Senior Revenue Cycle Manager, Compliance Manager, clinical leadership, and HIM to improve documentation workflows.
• Act as a liaison between coders and providers to clarify medical record entries and coding concerns.
• Assist in process improvement initiatives to enhance efficiency and accuracy in documentation practices.
• Analyze coding and documentation trends to provide insights for operational improvements.
• Utilize reports on provider documentation performance and compliance metrics.
• Assist in optimizing revenue cycle performance through documentation enhancement strategies.
Qualifications:Education & Experience
• Associate or bachelor’s degree or relevant work experience.
• 3 years of experience in medical coding, documentation improvement, revenue cycle management, or healthcare compliance.
• Experience with OBGYN, Behavioral Health, laboratory services, and Rural Health visit coding preferred.
Additional Licenses, Certifications and/or Specialty Requirements:
- CPC, CPMA Required.
- COBCG and CCDS preferred.
- Significant experience within the EpicCare EHR system including Cadence and Resolute environments, as well as reporting functionality.
- A valid driver’s license and access to a vehicle for occasional travel to clinical sites will be necessary for training, audits, or meetings with clinical staff.
Salary : $36 - $50