Medical Coding & Prior Authorization Specialist

The Medical Coding and Prior Authorization Specialist plays a dual role in supporting accurate clinical documentation and ensuring timely authorization of services for patients at Crossing Rivers Health. This position is responsible for coding all/assigned encounter types; reviewing and correcting coding related denials and managing prior authorization processes for specialty services, surgical procedures, therapies and imaging. The goal of this role is to support compliance, maximize reimbursement and ensure patients have timely access to medically necessary care.

Essential Job Functions

• Reviews clinical documentation to ensure coding accuracy, completeness, and compliance with regulations.
• Assigns diagnoses, procedural/treatment, professional billing codes for all patient type encounters (Clinic, Center for Specialty Care, Emergency, Urgent Care, Outpatient Services, Lab, Imaging, Physical/Occupational/Speech Therapy, Surgery, Observation/Inpatient, Obstetrics) utilizing ICD-10-CM, ICD-10-PCS or CPT guidelines
• Working knowledge of modifier usage, CCI edits, HCPCS, LCD/NCI regulations
• Data entry/verification/appropriate sequencing into electronic health record
• Submit provider queries as appropriate following approved guidelines.
• Identify and resolve clinical documentation and charge capture data discrepancies
• Initiates and manages prior authorization requests for surgical procedures, specialty services, imaging, and rehabilitation therapies.
• Verifies medical necessity and payer-specific criteria prior to submission of authorization requests.
• Assists with denial follow-up and appeals related to coding or prior authorization
• Collaborates with providers, nursing staff, and scheduling teams to obtain required clinical documentation for approvals.
• Monitors pending authorizations, ensuring timely follow-up and communication with payers, providers, and patients.
• Tracks and reports trends in authorization denials and coding discrepancies; participates in denial prevention initiatives.
• Maintains current knowledge of payer guidelines, coding updates, and regulatory requirements.
• Supports staff and providers through education on documentation and authorization best practices.
• Contributes to a culture of accountability, continuous improvement, and patient-centered service.
• Assist in provider education in use of coding guidelines and practices and proper documentation techniques
• Assist with coding quality review activities for accuracy and compliance monitoring
• Commitment to continuous learning as required to stay up-to-date on coding and prior authorization guidelines.
• Other job duties and responsibilities as assigned to effectively meet the needs of the patients, the department, and the organization as a whole.

Competencies

• Accountability – Ability to accept responsibility and account for his/her actions.
• Accuracy – Ability to perform work accurately and thoroughly.
• Business Acumen – Ability to grasp and understand business concepts and issues.
• Communication – The ability to get one’s ideas across to others through oral or written means and to understand the ideas of others through effective listening skills.
• Detail Oriented – Ability to pay attention to the minute details of a project or task.
• Ethical – Ability to demonstrate conduct conforming to a set of values and accepted standards.
• Honesty/ Integrity – Ability to be truthful and be seen as credible in the workplace.
• Organized – Possessing the trait of being organized or following a systematic method of performing a task.
• Reliability – The trait of being dependable and trustworthy.
• Responsible – Ability to be held accountable or answerable for one’s conduct.

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

Education

• High School Graduate or General Education Degree (GED) : Required
• Associate’s Degree in Health Information Management, Medical Coding, or related field: Required
• Registered Health Information Technician or related certification within 6 months of hire.

Experience

• 2+ years of medical coding experience in a Critical Access Hospital or similar setting preferred.
• Prior authorization and insurance verification experience preferred.

Computer Skills

• Proficient in Microsoft Office
• Epic experience preferred