Certified Coding Specialist

What you'll do:

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.

Responsibilities/Duties:

Complex Surgical Coding

• Code high-complexity orthopedic and neurosurgical procedures
• Verifying all documentation is complete and compliant
• Assigns codes for reimbursements, research and compliance with regulatory requirements utilizing guidelines.
• Follows coding conventions and ensure accurate assignment of:
• CPT (including add-on codes, modifiers, bundling rules)
• ICD-10 diagnoses supporting medical necessity
• Validate:
• Levels, laterality, approach (anterior/posterior)
• Instrumentation and graft usage
• Identify missed billable components (e.g., additional levels, hardware, biologics)
• Query provider for any necessary clarification related to unclear, unspecified or missing/incomplete documentation
• Apply payer-specific coding rules and edits

Denial Prevention & Root Cause Ownership

• Researches, analyzes, recommends, and facilitates a plan of action to correct discrepancies and prevent future coding errors:
• Review coding-related denials (medical necessity, bundling, documentation)
• Perform root cause analysis and trend identification
• Partner with RCM and vendor teams to implement corrective actions
• Develop coding edits and pre-bill review processes for high-risk procedures

Pre-Bill Quality Review

• Perform targeted pre-bill audits for:
• High-dollar orthopedic surgeries
• Multi-level and complex cases
• Ensure documentation supports:
• Medical necessity
• Procedure specificity
• Escalate documentation gaps prior to claim submission

Provider Documentation Improvement

• Partner with surgeons to improve documentation quality
• Provide targeted, case-based feedback:
• Missing elements impacting coding accuracy
• Opportunities to fully capture procedure complexity
• Support education on:
• Modifier usage
• Documentation specificity (levels, implants, approach)

Vendor Oversight & Coding Quality Control

• Audit external coding vendor performance (if applicable)
• Identify discrepancies between internal and vendor coding
• Provide feedback and enforce coding standards
• Support development of SOPs and coding guidelines
• Serves as primary resource and Spire Point of Contact (SPOC) between provider and vendor

Appeals

• Support appeals for coding-related denials
• Provide clinical/coding rationale and documentation validation
• Partner with AR teams on high-value accounts