• Responsible for abstracting and assigning valid CPT, ICD-9/10, and HCPCS codes • Identify compliance concerns, trends, and educational opportunities • Work independently with limited oversight • Accurately abstract information from service documentation • Assign appropriate CPT, ICD-9/10, and HCPCS codes • Communicate professionally with providers and management • Responsible for coding encounters in a timely manner • Meet or exceed coding production and quality standards • Understand and apply regulatory changes • Review and resolve denials

• Responsible for performing audits and coding patient charts at the appropriate timepoints in care. • Review assessments and plans of care to ensure that the coded diagnoses on patient charts are accurately reflected in assessment and plan of care documentation. • Utilizes computerized coding/abstracting equipment, codes all diagnoses/procedures in accordance with coding guidelines while meeting quality and productivity standards. • Provides necessary assistance to field staff and leadership to Outcome and Assessment Information Set (OASIS), Healthy Outcomes from Positive Experiences (HOPE), and/or ICD-10 queries. • Assists coders and quality review staff in performance of duties. • Maintains and reports statistical information when applicable. • Reviews daily reports to ensure all records are processed. • Consults with field clinical staff regarding appropriate ICD codes and sequencing. • Performs other duties as assigned.

• Code physician charges by assigning ICD-10, CPT, HCPCS codes and modifiers from medical record documentation • Utilize multiple resources to support code assignment • Resolve coding denials and pre-bill coding edits • Meet or exceed productivity standards • Meet or exceed accuracy rate of 95.5% in monthly internal audits • Effectively present coding issues to internal team members, internal clients, or external clients • Deliver information in a one-on-one or small group format to peers • Meet deadlines and complete assignments before monthly closing dates • Locate and apply CCI, LCD, NCD and other applicable coding rules and client specific guidelines • Other duties as assigned

• Review and abstract professional medical records, including provider notes, encounters, and supporting documentation. • Assign ICD-10-CM, CPT, HCPCS, and applicable modifiers accurately, following national and payer-specific coding guidelines. • Validate that all codes are supported by provider documentation; query providers for clarification when necessary. • Maintain coding quality metrics (accuracy, productivity, and compliance) as defined by leadership. • Participate in internal and external coding audits; provide feedback to improve documentation and coding processes. • Stay current with updates to CPT, ICD-10, HCPCS, and CMS risk adjustment guidelines. • Maintain confidentiality and adhere to all HIPAA and compliance standards.