<p>What you'll do:</p> <p>The Certified Coding Specialist is responsible for accurate and compliant coding of complex orthopedic procedures across all care settings. This role directly impacts revenue integrity by ensuring optimal CPT/ICD-10 coding, minimizing denials, and supporting provider's documentation improvement.</p> <p>Responsibilities/Duties:</p> <p>Complex Surgical Coding</p> <ul> <li>Code high-complexity orthopedic and neurosurgical procedures </li><li>Verifying all documentation is complete and compliant </li><li>Assigns codes for reimbursements, research and compliance with regulatory requirements utilizing guidelines. </li><li>Follows coding conventions and ensure accurate assignment of: </li><li>CPT (including add-on codes, modifiers, bundling rules) </li><li>ICD-10 diagnoses supporting medical necessity </li><li>Validate: </li><li>Levels, laterality, approach (anterior/posterior) </li><li>Instrumentation and graft usage </li><li>Identify missed billable components (e.g., additional levels, hardware, biologics) </li><li>Query provider for any necessary clarification related to unclear, unspecified or missing/incomplete documentation </li><li>Apply payer-specific coding rules and edits </li></ul> <p>Denial Prevention & Root Cause Ownership</p> <ul> <li>Researches, analyzes, recommends, and facilitates a plan of action to correct discrepancies and prevent future coding errors: </li><li>Review coding-related denials (medical necessity, bundling, documentation) </li><li>Perform root cause analysis and trend identification </li><li>Partner with RCM and vendor teams to implement corrective actions </li><li>Develop coding edits and pre-bill review processes for high-risk procedures </li></ul> <p>Pre-Bill Quality Review</p> <ul> <li>Perform targeted pre-bill audits for: </li><li>High-dollar orthopedic surgeries </li><li>Multi-level and complex cases </li><li>Ensure documentation supports: </li><li>Medical necessity </li><li>Procedure specificity </li><li>Escalate documentation gaps prior to claim submission </li></ul> <p>Provider Documentation Improvement</p> <ul> <li>Partner with surgeons to improve documentation quality </li><li>Provide targeted, case-based feedback: </li><li>Missing elements impacting coding accuracy </li><li>Opportunities to fully capture procedure complexity </li><li>Support education on: </li><li>Modifier usage </li><li>Documentation specificity (levels, implants, approach) </li></ul> <p>Vendor Oversight & Coding Quality Control</p> <ul> <li>Audit external coding vendor performance (if applicable) </li><li>Identify discrepancies between internal and vendor coding </li><li>Provide feedback and enforce coding standards </li><li>Support development of SOPs and coding guidelines </li><li>Serves as primary resource and Spire Point of Contact (SPOC) between provider and vendor </li></ul> <p>Appeals</p> <ul> <li>Support appeals for coding-related denials </li><li>Provide clinical/coding rationale and documentation validation </li><li>Partner with AR teams on high-value accounts </li></ul>