Finance_Certified_Coder

As the Certified Coder for SDCHC, the position will be responsible for ensuring accurate, complete, and compliant medical coding practices across the organization in compliance with HRSA Section 330, Medi-Cal, and Medicare requirements. The Certified Coder bridges clinical documentation and billing by reviewing provider-documented encounters, verifying and assigning ICD-10-CM, CPT, and HCPCS codes, and supporting providers through coding education and documentation feedback. Working closely with the CFO and revenue cycle staff, this role serves as the organization's primary coding resource, protecting PPS/wraparound reimbursement, UDS reporting accuracy, HEDIS and quality measure capture, and audit readiness consistent with HRSA Health Center Program requirements and Section 330 grant compliance. The responsibilities of coding compliance include the development, implementation, education, data collection, and analysis of coding accuracy across the organization. The position includes detection, monitoring, prevention, reporting, and correction of coding errors, documentation gaps, and potential compliance risk. It also includes support for payer audits, HRSA site visits, and OIG-related inquiries. The person responsible for coding compliance cultivates a culture of accuracy and accountability through provider education, clear guidance, and open communication. Essential Duties and Responsibilities: Primary Functions: Coding Review & Verification Reviews, verifies and updates ICD-10-CM, CPT, and HCPCS Level II codes assigned to provider encounters prior to claim submission, ensuring alignment with documentation, medical necessity, and FQHC-specific billing rules (e.g., PPS encounter definitions, qualifying visit codes, G0466–G0470 series) with a 48-hour claims submission deadline from visit date. Conducts retrospective and concurrent coding audits, including 100% review of high-risk encounter types (new patient E/M, behavioral health, care coordination, quality-incentive-linked visits) and periodic sampling across all providers. Tracks and trends coding error patterns organization-wide and reports findings to the CFO and relevant department leadership Provider Support & Education (Primary Responsibility) Identifies documentation gaps and communicates individualized, constructive feedback to providers through a structured Clinical Documentation Improvement (CDI) feedback loop. Serves as the primary coding resource for clinical and billing staff, answering day-to-day coding questions and escalating ambiguous scenarios to the CFO. Delivers periodic (at minimum annual) coding and documentation training for providers and clinical staff, tailored to FQHC-specific requirements, payer updates, and audit findings. Maintains and updates internal coding guidelines, quick-reference tools, and EHR templates/order sets in collaboration with clinical informatics and revenue cycle staff. Regulatory & Policy Monitoring Monitors and interprets changes in Medi-Cal, Medicare, and state-only billing policy affecting FQHC coding (e.g., AB 116 state-only services transition, scope-of-service changes, sliding fee scale interactions) and translates them into actionable coding guidance. Supports HEDIS, UDS, GPRA, and grant-specific quality reporting by ensuring diagnosis and service codes accurately reflect care delivered, including chronic condition and risk-adjustment-relevant capture. Keeps up to date with new and revised state and federal coding and billing regulations. Reviews and evaluates related policies and procedures and recommends revisions as needed. Audit & Compliance Support Assists with responses to payer audits, HRSA Operational Site Visits (OSV), and OIG-related inquiries by compiling documentation and coding evidence. Maintains strict confidentiality of patient health information in accordance with HIPAA and 42 CFR Part 2 where applicable. Analyzes coding audit reports and advisories that identify compliance risk and billing accuracy pa…