Reporting to the Manager of Professional Coding, the Professional Coding Specialist is responsible for the accurate review, interpretation, and assignment of ICD-10-CM, CPT, and HCPCS Level II codes for physician and other qualified healthcare provider services. This role ensures coding accuracy and compliance with federal regulations, payer guidelines, and organizational policies to support appropriate reimbursement and minimize audit risk.
The Coding Specialist collaborates with providers, revenue cycle teams, and clinical teams to ensure complete, accurate, and compliant documentation and coding practices. Reporting to the Manager of Professional Coding, the Professional Coding Specialist is responsible for the accurate review, interpretation, and assignment of ICD-10-CM, CPT, and HCPCS Level II codes for physician and other qualified healthcare provider services.
This role ensures coding accuracy and compliance with federal regulations, payer guidelines, and organizational policies to support appropriate reimbursement and minimize audit risk. The Coding Specialist collaborates with providers, revenue cycle teams, and clinical teams to ensure complete, accurate, and compliant documentation and coding practices. Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers and one another.
In addition to our values, all employees are expected to demonstrate the core Success Factors which tell us how we work together and how we get things done. The core Success Factors include: Instill Trust and Value Differences Patient and Community Focus and Collaborate
Enters codedbstracted information into 3M 360 Finder assigning accurate APC and reviewing all coding edits appearing in 3M. Understands and follows all National Correct Code Initiative Edits (NCCI) and follows pertinent medical necessity requirements. Resolves accounts on the claims edit database.
Assigns injections and infusion codes for observation patients. Meets the minimum productivity standard mintaining an average accuracy rating of 95%. Assigns E/M, ICD-10-CM, CPT or chargemaster codes to clinic visits ensuring medical record documentation supports the code.
Should physicians have entered in diagnosis, ICD or CPT codes, ensures they are accurate and supported by documentation in the medical record. Utilizes 3M to identify and resolve NCCI edits before final billing. Reports documentation insufficiencies to the responsible physician.
Follows Rhode Island Hospital Facility Coding Guidelines for adult patients and 1995 Evaluation and Management Guidelines for patients less than 18 years of age. Monitors and resolves rejected accounts on the Claims Edit Report and e Clinical Works error reports by established timeframe researching coding conflicts including chargemaster, medical necessity and various other coding and billing issues. Refers complex coding issues to the coding validator or supervisor.
Reviews pertinent outpatient uncoded reports researching and resolving old uncoded accounts and any accounts posted on report for which the charges are inappropriate. Updates patient financial accounts in the Patient Management and Patient Accounting billing system as required. Follows established procedures for rebilling accounts.
Performs related clerical duties as required. Maintains level of knowledge and expertise pertinent to the position. Compliance & Regulatory Adherence Maintain compliance with CMS regulations, National Correct Coding Initiative (NCCI) edits, Medicare Administrative Contractor (MAC) guidance, payer policies and organizational policies.
Participate in compliance initiatives to reduce coding-related denials and audit findings. Ensures compliance with HIPAA , organizational data privacy , and security policies . Query compliance and appropriateness in accordance with ACDIS/AHIMA Guidelines for Achieving a Compliant Query Practice Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and the American Association of Professional Coders .
Performance Metrics Meets or exceeds 95% coding accuracy rate Achieves productivity benchmarks Demonstrates consistent performance in accuracy, timeliness, and workload management Adheres to organizational coding guidelines, payer requirements, and documentation standards to support audit readiness and reimbursement integrity Accurately resolves coding edits, denials, and discrepancies
Education High school diploma or equivalent required Certifications One or more of the following required: CPC (Certified Professional Coder) – AAPC CCS or CCS-P (Certified Coding Specialist / Physician-based) – AHIMA Experience 1–3+ years of professional (physician-based) coding experience Specialty experience a plus Strong knowledge of: ICD-10-CM, CPT, and HCPCS Level II coding guidelines Medical terminology, anatomy, and healthcare documentation Ability to interpret complex medical documentation and apply coding guidelines accurately Strong written and verbal communication skills Proficiency with electronic health records (EHR), Epic experience preferred E/M coding and/or surgical/procedural coding Work Environment Fully Remote: Must maintain a secure, private workspace to protect PHI .
Required to use organization-approved secure systems (VPN, multi-factor authentication) . Maintains active communication via email, messaging platforms, and attends virtual meetings , as scheduled. Working conditions: Requires long periods of computer use to review medical records .
Ability to meet deadlines while achieving productivity and accuracy standards. Independent action: Demonstrates ability to work independently within the department’s policies and practices. Refers specific complex problems to the supervisor when clarification of the departmental policies and procedures are required .
Supervisory responsibility: None Disclaimer This job description is intended to describe the general nature and level of work performed. Duties and responsibilities may be adjusted based on organizational needs and regulatory requirements.
$24.29-$40.07 EEO Statement: Brown University Health is committed to providing equal employment opportunities and maintaining a work environment free from all forms of unlawful discrimination and harassment. Location: Corporate Headquarters - 15 LaSalle Square Providence, Rhode Island 02903 Work Type: M-F 8am-4:30pm Work
Day Daily Hours: 8 hours Driving Required: No