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Medical Coding Specialist in Orange at Prospect Medical Systems

Date Posted: 1/8/2019

Job Snapshot

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Job Description

Medical Coding Specialist

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

Under general supervision, this position evaluates hospital medical records to ensure completeness, accuracy, and compliance with the International Classification of Diseases Manual - Clinical Modification (ICD-9-CM), and the American Medical Association's Current Procedural Terminology manual (CPT) for appropriate billing, prior to payment of hospital claims. Provides technical guidance and education to medical management and claims staff regarding coding and medical chart review process. This position will also assist the Hierarchical Condition Categories (HCC) Risk Adjustment department with review and audit of incoming medical records from PCPs and specialists for appropriate identification of member’s HCC.  The position will also ensure compliance with CMS rules and regulations, health plan audit requirements and coding guidelines.  

Job Responsibilities/Duties

  • Evaluates medical record documentation and coding to ensure that diagnostic and procedural codes and other documentation accurately reflect and support the inpatient and outpatient visit, and to ensure that data comply with legal standards and guidelines; interprets medical information such as diseases or symptoms, and diagnostic descriptions and procedures for a given visit in order to review and validate hospital claims are accurately billed and reflect the correct DRG, ICD-9-CM and CPT codes to ensure appropriate payment of hospital claim. 

  • Reviews Medicare reimbursement claims for appropriate DRGs, completeness and accuracy prior to release of payment. 

  • Evaluates records and prepares reports, on such topics as number of approved and denied claims or documentation or coding issues, for review by management; makes recommendations for changes in policies and procedures

  • Provides technical guidance to medical management and claims staff in identifying and resolving issues or errors, such as incomplete or missing records and documentation, ambiguous or nonspecific documentation, or codes that do not conform to approved coding principles/guidelines;

  • Educates and advises staff on codes, documentation, procedures, and requirements; identifies training needs, prepares training materials, and conducts training for physicians and support staff to improve skills in the review and audit of coding quality health data.

  • Reviews bulletins, newsletters, and periodicals, and attends workshops to stay abreast of current issues, trends, and changes in the laws and regulations governing medical record coding and documentation; develops and updates procedures manuals to maintain standards for correct coding, minimize the risk of fraud and abuse, and minimize overpayment of claims.

  • Abstract pertinent information from assigned medical records using ICD-9-CM, CPT and/or HCPCS codes.

  • Provide management with input on provider performance from assigned audits and special projects

  • Document all chart audit findings in IDX system and applicable audit tools

  • Ensure all captured diagnoses is properly documented and supported within progress note according to CMS rules and regulations including but not limited to encounter date, legibility, proper provider signature and member identification requirements.

  • Report noncompliance issues detected through auditing.

  • Adheres to Official Coding Guidelines.

  • Research and provide courteous, accurate and timely response to inquires by providers as

  • related to HCC Risk Adjustment projects and reports.


Minimum Education: Bachelor’s Degree or equivalent work experience.

Minimum Experience: Two years of experience in medical record coding.

Req. Certification/Licensure: Possession of an Accredited Record Technician's certification (ART) or Certified Coding Specialist designation (CCS) issued by the American Health Information Management Association.

Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals you will receive:

  • Company 401K
  • Medical, dental, vision insurance
  • Paid time-off
  • Life insurance

How to Apply

To apply for this role, or search our other openings, please visit and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

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