Medical Coding & Prior Authorization Specialist

Essential Job Functions

• Reviews clinical documentation to ensure coding accuracy, completeness, and compliance with regulations.
• Assigns diagnoses, procedural/treatment, professional billing codes for all patient type encounters (Clinic, Center for Specialty Care, Emergency, Urgent Care, Outpatient Services, Lab, Imaging, Physical/Occupational/Speech Therapy, Surgery, Observation/Inpatient, Obstetrics) utilizing ICD-10-CM, ICD-10-PCS or CPT guidelines
• Working knowledge of modifier usage, CCI edits, HCPCS, LCD/NCI regulations
• Data entry/verification/appropriate sequencing into electronic health record
• Submit provider queries as appropriate following approved guidelines.
• Identify and resolve clinical documentation and charge capture data discrepancies
• Initiates and manages prior authorization requests for surgical procedures, specialty services, imaging, and rehabilitation therapies.
• Verifies medical necessity and payer-specific criteria prior to submission of authorization requests.
• Assists with denial follow-up and appeals related to coding or prior authorization
• Collaborates with providers, nursing staff, and scheduling teams to obtain required clinical documentation for approvals.
• Maintains current knowledge of payer guidelines, coding updates, and regulatory requirements.
• Supports staff and providers through education on documentation and authorization best practices.
• Contributes to a culture of accountability, continuous improvement, and patient-centered service.

Competencies

• Accountability – Ability to accept responsibility and account for his/her actions.
• Accuracy – Ability to perform work accurately and thoroughly.
• Business Acumen – Ability to grasp and understand business concepts and issues.
• Communication – The ability to get one’s ideas across to others through oral or written means and to understand the ideas of others through effective listening skills.
• Detail Oriented – Ability to pay attention to the minute details of a project or task.
• Ethical – Ability to demonstrate conduct conforming to a set of values and accepted standards.
• Honesty/ Integrity – Ability to be truthful and be seen as credible in the workplace.
• Organized – Possessing the trait of being organized or following a systematic method of performing a task.
• Reliable – The trait of being dependable and trustworthy.
• Responsible – Ability to be held accountable or answerable for one’s conduct.

Requirements

• Education: High School Graduate or General Education Degree (GED): Required
• Associate’s Degree in Health Information Management, Medical Coding, or related field: Required
• Registered Health Information Technician or related certification within 6 months of hire.
• Experience: 2+ years of medical coding experience in a Critical Access Hospital or similar setting preferred.
• Prior authorization and insurance verification experience preferred.
• Computer Skills: Proficient in Microsoft Office
• Epic experience preferred.