Medical Documentation Coding Specialist – Family Medicine | Permanent WFH

We are seeking an experienced Medical Documentation Coding Specialist – Family Medicine to support accurate, timely, and compliant clinical documentation and charge capture. The ideal candidate will have at least 3 years of experience in family medicine, medical documentation, coding, clinical chart review, or a related healthcare setting .

Key Responsibilities

AI-Assisted Clinical Documentation

• Review AI-generated clinical documentation in AdvancedMD after the provider saves the patient encounter.
• Edit, organize, and complete SOAP notes to ensure accuracy, completeness, clarity, and clinical appropriateness.
• Complete and finalize the Assessment & Plan (A&P) based on the provider's documented recommendations and treatment plan.
• Ensure pertinent patient history, physical examination findings, diagnoses, assessments, and treatment plans are accurately documented.
• Verify documentation for completeness and accuracy before routing the chart to the provider for review and sign-off.
• Identify missing, inconsistent, or unclear documentation and follow established procedures for clarification when necessary.

Clinical Documentation & EHR Management

• Complete the physical examination section using the provider's documented findings.
• Enter and document laboratory, imaging, and other diagnostic study results reviewed during the encounter.
• Document all Point-of-Care (POC) testing performed in the office, including test results.
• Enter CURES review dates and other required controlled-substance monitoring information, as applicable.
• Ensure clinical documentation is accurately entered, properly organized, and appropriately formatted within AdvancedMD.
• Maintain consistency and accuracy across the patient's medical record.
• Follow established documentation workflows and quality standards.

Charge Capture & Coding Support

• Complete charge slips for each patient encounter.
• Accurately document and capture:
  • ICD-10-CM diagnoses
  • CPT procedure codes
  • Appropriate office visit/E&M level
  • Point-of-Care testing
  • Injections and vaccines
  • Other billable services provided during the encounter
• Ensure all services rendered are supported by appropriate clinical documentation.
• Review encounters for potential missing charges or documentation that may affect accurate reimbursement.
• Apply current coding guidelines and organizational policies when performing documentation and coding-related duties.

Compliance & Confidentiality

• Maintain strict compliance with HIPAA and applicable healthcare privacy and security regulations.
• Protect the confidentiality and security of all Protected Health Information (PHI).
• Maintain accurate and complete medical records in accordance with organizational policies and applicable regulatory requirements.
• Follow clinic standards for documentation, coding, record retention, and medical record integrity.
• Maintain professional discretion when handling sensitive patient and clinical information.

Qualifications

• Minimum 3 years of experience in medical documentation, clinical documentation, medical coding, chart review, or a related healthcare role.
• Experience working in Family Medicine or a primary care setting strongly preferred.
• Strong knowledge of medical terminology and clinical documentation.
• Working knowledge of ICD-10-CM and CPT coding.
• Familiarity with Evaluation and Management (E/M) coding and charge capture.
• Experience documenting or reviewing laboratory, imaging, POC testing, injections, vaccines, and other outpatient services.
• Experience with an EHR system; AdvancedMD experience is highly preferred.
• Understanding of HIPAA and medical record confidentiality requirements.
• Excellent attention to detail and ability to identify documentation discrepancies.
• Strong written and verbal communication skills.
• Ability to work independently, manage multiple encounters, and meet documentation deadlines.
• Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent credential.
• Experience with AI-assisted clinical documentation platforms.
• Experience with CURES/controlled-substance monitoring documentation.
• Familiarity with outpatient family medicine coding and billing workflows.
• Experience working with U.S.-based healthcare providers and medical practices.
• Amenable to work during US hours
• Must be willing to undergo a background check as part of the hiring process.

Perks

• Permanent Work From Home
• Leave Credits
• Monetary Allowance <