Clinical Documentation Specialist

Job Position: We are seeking a Clinical Documentation Specialist to play a crucial role in reviewing medical records and accurately assigning medical codes for orthopaedic procedures and services.

Responsibilities:

• Review and assign accurate medical codes for diagnoses, procedures, and services using ICD-10, CPT, and HCPCS guidelines.
• Ensure compliance with federal, state, and payer regulations, as well as internal policies.
• Collaborate with physicians, clinical staff, and billing team to clarify documentation and resolve discrepancies.
• Monitor and stay updated on coding changes, regulations, and payer requirements.
• Assist with audits and quality assurance activities to minimize claim denials.

Qualifications:

• Preferred: Certification as a CPC (Certified Professional Coder), COC (Certified Outpatient Coder), or equivalent credential.
• 2+ years of orthopaedic medical coding experience.
• Strong knowledge of medical terminology, anatomy, and physiology — especially as it relates to musculoskeletal care.
• Proficient in EMR/EHR systems and Microsoft Office Suite.

Work Environment:

• Requires prolonged periods of sitting at desk and working at computer.
• Must have good computer and telephone communication skills and able to operate miscellaneous office equipment.
• Hearing and vision abilities within normal range, or corrected, to observe and communicate with patients and staff.
• Ability to work in fast-paced environment in a professional medical office setting.

Benefits:

• Health, Dental, and Vision Insurance.
• 401k Plan, 3% Safe Harbor Non-Elective Employer Contribution.
• Group Life Insurance.
• Voluntary Life Insurance.
• Short-Term and Long-Term Disability.
• Accident, Hospital, Critical Illness/Cancer Benefits.
• Mileage Reimbursement for travel between office locations.
• Reimbursement for certifications and continuing education.
• Accrual Paid Time Off (up to 19 days off within first year).

Searchable Title: Clinical Documentation Specialist Medical Coder Orthopaedic Healthcare Team