• Review clinical documentation to assign and sequence diagnostic and procedural codes for specific patient types to meet the requirements of hospital data or physician data retrieval for billing and reimbursement. • Validate APC calculations to accurately capture the diagnoses/procedures documented in the clinical record for hospitals. • Perform documentation review and assessment for accurate abstracting of clinical data to meet regulatory and compliance requirements. • Interact with client staff and providers as needed. • Select and sequence ICD-10, and/or CPT/HCPCS codes for designated patient types including but not limited to: Ancillary (Diagnostic)/ Recurring; Hospital, Clinic; Physician Pro Fee; Technical Fee or Evaluation and Management. • Review and analyze facility records to ensure that APC assignments and/or Evaluation and Management codes accurately reflect the diagnoses/procedures documented in the clinical record. • Complete assigned work functions utilizing appropriate resources. • Maintain strict patient and provider confidentiality in compliance with all HIPAA Guidelines. • Participate in client and Savista staff meetings, trainings, and conference calls as requested and/or required. • Maintain current working knowledge of ICD-10 and/or CPT/HCPCS and coding guidelines, government regulations, protocols and third-party requirements regarding coding and/or billing. • Participate in continuing education activities to enhance knowledge, skills, and maintain current credentials.

• Accurately code diagnoses based on documented information, ensuring compliance with regulatory requirements and that the assigned codes accurately represent the clinical information documented by the provider • Ensure documentation supports appropriate level(s) of care and severity of illness when applying ICD-10, CPT, and other relevant codes for billing and regulatory compliance • Maintain a 95% productivity rate • Communicate with physicians and other healthcare providers to clarify documentation, ensuring that diagnoses and procedures are properly documented in compliance with clinical standards • Issue queries to healthcare providers when documentation appears ambiguous, incomplete, or inconsistent, requesting clarification or additional details be added to the medical record to ensure accurate documentation • Ensure that the queries are compliant with industry standards and regulatory guidelines • Stay updated on current coding guidelines, clinical protocols, and regulatory changes, including Medicare and Medicaid guidelines on billing and coding, to support provider compliance therewith • Assist in improving the quality of clinical documentation to support various quality initiatives, such as HEDIS, CMS, and other contractual or enterprise-initiated performance metrics • Participate in performance improvement projects aimed at improving documentation practices and outcomes • Conduct audits of medical records to identify trends in documentation, both positive and negative, to help the organization improve documentation practices and provider education efforts • Provide ongoing education to clinical staff, coders, and other healthcare providers on best practices in clinical documentation, coding guidelines, and regulatory compliance • Develop training programs to address documentation deficiencies and improve overall documentation quality • Collaborate with departments such as compliance, revenue cycle, and quality management to optimize the documentation improvement process • Other duties consistent with this role, as assigned.

Ensure accurate coding, billing, and reimbursement by reviewing and submitting claims, resolving discrepancies, and collaborating with teams to optimize revenue cycle performance while maintaining compliance with industry standards.

• Utilize available encoder, grouper software, and other coding resources to determine the appropriate ICD-10-CM, CPT, and/or HCPCS including specialty specific codes and Evaluation and Management (E&M) codes • Maintain an understanding and apply knowledge of National Correct Coding Initiatives (NCCI), Local Coverage Documents and National Coverage Documents (LCD/NCD) directives, Medically Unlikely Edits (MUEs), and Medicare Teaching Physician Guidelines