Medical Coding Specialist at Trillium Health Inc. – Rochester, New York

Job Title

Medical Coding Specialist

Department

Revenue Cycle

Position Type

Full-Time

FLSA

Non-Exempt

The Medical Coding Specialist is responsible for reviewing medical records and encounter documentation to ensure accurate, complete, and compliant coding in accordance with ICD-10-CM and CPT guidelines. Under the supervision of the Director of Revenue Cycle and Billing, this role supports compliant billing practices, maximizes reimbursement, and ensures adherence to federal, state, and payer regulations, including those specific to Federally Qualified Health Centers (FQHCs).

The Medical Coding Specialist collaborates closely with providers, billing staff, and other members of the healthcare team to clarify documentation, resolve coding issues, and promote best practices in clinical documentation and coding accuracy.

• Review and analyze patient records and clinical documentation to ensure completeness and accuracy for coding purposes.
• Assign and sequence diagnosis and procedure codes using ICD-10-CM and CPT for all services rendered.
• Apply coding guidelines and regulatory requirements to ensure correct code assignment and compliance.

• Adhere to national coding standards, payer policies, and regulatory requirements.
• Stay current on coding rules, regulations, and industry trends through ongoing education and training.

• Communicate with providers to clarify missing, incomplete, or unclear documentation.
• Provide education and feedback to clinical staff on documentation best practices to support accurate coding.
• Participate in team meetings related to patient care, billing, and coding updates.

• Accurately translate medical procedures and diagnoses into codes for submission to payers.
• Ensure timely submission of coding information to support claims processing and reimbursement.
• Collaborate with billing staff to resolve coding-related claim issues.

• Maintain strict confidentiality of patient information in compliance with HIPAA and privacy laws.
• Ensure coded medical records are stored securely and accurately.
• Keep coding manuals and guidelines current and updated.

• Pursue ongoing professional development to remain proficient in medical coding.
• Attend workshops, seminars, and training sessions as needed.
• Serve as a resource or mentor to less experienced coding staff when applicable.
• Assist with automation of cash receipt applications and perform other duties as assigned.

• Proficiency in medical terminology, ICD-10-CM, and CPT coding systems
• Strong attention to detail and accuracy
• Knowledge of FQHC billing and reimbursement regulations
• Effective written and verbal communication skills
• Ability to work collaboratively with clinical and administrative teams
• Ability to relate to individuals from diverse backgrounds, cultures, races, sexual orientations, and gender identities

• Associate’s Degree in Health Information Management or a related field required
• Professional coding certification required (CPC, CCS, or equivalent)
• Minimum of 3–4 years of professional fee coding experience
• Commitment to continuous learning and staying current with coding regulations and healthcare requirements

While performing the duties of this job, the employee is regularly required to sit, stand, walk, use hands to finger, handle or feel; reach with hands and arms; and talk or hear. The employee may occasionally need to stoop, bend, and lift or move up to 25 pounds. Specific vision abilities include close vision, distance vision, peripheral vision, depth perception, and the ability to adjust focus.

Trillium Health promotes Equal Employment Opportunity for all, respecting diverse backgrounds, cultures, races, ages, experiences, and opinions. Employees are expected to meet departmental performance standards and participate in compliance audits, process improvement initiatives, and quality improvement plans