Evaluates medical record documentation and charge ticket coding to optimize reimbursement by ensuring that diagnostic and procedural codes and other documentation accurately reflect and support the 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 accurately assign and sequence the correct ICD-10-CM and CPT codes;

Medicare reimbursement claims before submission for completeness and accuracy and to minimize claim denial; evaluates records and prepares reports, on such topics as number of denied claims or documentation or coding issues, for review by management and/or professional evaluation committees; makes recommendations for changes in policies and procedures; assists data processing staff in revising the computer master file as required.

Provides technical guidance to physicians and other departmental 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 proper code selection, documentation, procedures, and requirements; identifies training needs, prepares training materials, and conducts training for physicians and support staff to improve skills in the collection and coding of 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 optimize revenue recovery.