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.
This role will review and refine AI-assisted clinical documentation within
AdvancedMD, complete and organize SOAP notes and Assessment & Plan documentation, accurately capture diagnoses and procedures, and ensure that all billable services are properly documented for coding and billing purposes.
The successful candidate must have strong knowledge of
family medicine workflows, medical terminology, ICD-10-CM, CPT coding, clinical documentation standards, and HIPAA requirements.
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.
Perks
- Permanent Work From Home
- Leave Credits
- Monetary Allowance
- Annual Bonus
- Weekly Paychecks
- Fixed Weekends Off
- Thriving Company Culture with Complete Autonomy
- Exclusive Specialized Training Programs
- Unlock Your Potential with a Highly Competitive Salary
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Who are we
BizForce is one of the fastest-growing global outsourcing companies in the world, founded in the US in Tucson, Arizona and is now operational in PH!
Our Commitment to delivering high-quality results for our clients and the only way to do that is ensuring a rewarding, respectful and productive experience for our employees. We hold the same values for both our customers and our employees.
