Evaluates health record documentation and charges to optimize reimbursement by ensuring that diagnostic and procedural codes and other documentation accurately reflect and support the outpatient visit. Ensures that data complies with regulatory and coding guidelines. Reviews medical information, such as diseases or symptoms and diagnostic descriptions and procedures for a given visit, to accurately assign and sequence the correct ICD-10 CM, HCPCS and CPT codes. Adheres to the quality and productivity standards set by the department.

The Coding Specialist I performs Current Procedural Terminology (CPT) and International Classification of Diseases, volume 10 (ICD10) coding through abstraction of the medical record with a focus on Evaluation and Management services. This position trains physicians and other staff regarding documentation, billing and coding, and performs various administrative and clerical duties to support the roles core function. The Coding Specialist I also demonstrates understanding and knowledge to resolve Optum coding edits.