Position Overview

Responsible for the accurate and compliant coding of inpatient, outpatient, and professional OB/GYN encounters. This position serves as a key liaison between coding, clinical, and compliance departments ensuring that all documentation and coding practices meet regulatory and payer requirements. The role also includes providing ongoing education to OB/GYN providers and clinical staff on documentation quality, coding updates, and best practices to optimize compliance and reimbursement.

Tasks and Responsibilities

Coding and Documentation Review:

• Assign accurate ICD-10-CM, CPT, and HCPCS codes for all OB/GYN-related inpatient and outpatient encounters, including deliveries, surgeries, procedures, and E/M services.
• Apply knowledge of global obstetric coding, cesarean and vaginal deliveries, postpartum care, and gynecologic surgeries (e.g., hysterectomy, laparoscopic procedures).
• Review provider documentation to ensure completeness and accuracy before code assignment.
• Collaborate with clinical departments to resolve documentation or coding discrepancies.
• Validate coding accuracy in accordance with UHDDS, CMS, and hospital coding guidelines.

Provider Education & Training:

• Develop and deliver education programs for hospital-employed OB/GYN providers and residents on documentation and coding requirements.
• Conduct routine provider audits with feedback sessions to improve compliance and accuracy.
• Create educational tools, including coding reference sheets, pocket guides, and documentation tip sheets.
• Educate providers on changes in coding regulations (CPT, ICD-10-CM, HCPCS, and payer policy updates).
• Serve as a resource for physicians and staff regarding documentation improvement and charge capture.

Auditing & Compliance:

• Conduct regular internal audits of OB/GYN records to ensure adherence to coding and documentation standards.
• Identify trends in documentation deficiencies or coding errors and recommend corrective action plans.
• Work collaboratively with Compliance and Revenue Integrity teams to ensure adherence to federal, state, and payer regulations.
• Maintain confidentiality and compliance with HIPAA regulations.

Collaboration & Communication:

• Participate in departmental meetings, provider onboarding sessions, and compliance training.
• Support revenue cycle teams in addressing claim denials, coding queries, and charge reconciliation.

Education, Training and Previous Experience Requirements

Education:

• Associate’s degree or a related healthcare discipline preferred.
• Equivalent combination of education and experience may be considered.

Certification (Required):

• Current coding certification through AAPC or AHIMA: CPC, COC, CCS, or CCS-P.
• Specialty certification such as COBGC (Certified OB/GYN Coder) preferred.
• CPMA (Certified Professional Medical Auditor) or CDEO (Certified Documentation Expert – Outpatient) a plus.

Experience:

• Minimum 3–5 years of recent coding experience in a hospital or health system environment.
• Strong background in OB/GYN inpatient, outpatient, and surgical coding.
• Experience educating providers or leading documentation improvement initiatives preferred.
• Familiarity with EHR and coding systems such as Epic, Cerner, Meditech, or 3M.

Knowledge and Skills Needed to Perform Effectively in the Position

• Expert understanding of anatomy, physiology, and medical terminology related to obstetrics and gynecology.
• Comprehensive knowledge of ICD-10-CM, CPT, HCPCS, and payer-specific coding rules.
• Ability to interpret and apply CMS, AHA, and AMA coding guidelines.
• Excellent written, verbal, and presentation skills.
• Strong analytical, organizational, and problem-solving abilities.
• High attention to detail with a focus on accuracy and compliance.

Job Related Physical Abilities an Individual Needs in Order to Perform the Job in a Satisfactory Manner

Must be able to stand for long periods of time, bend and stoop.  Must be able to speak and hear sufficient to communicate with providers and others.  Ability to view a monitor/screen and enter data.  Ability to physically assist providers as needed.

Work Environment

• May be remote, hybrid, or on-site, depending on hospital policy.
• May require on-site presence for audits, education sessions, and provider meetings.
• Standard business hours; occasional flexibility for provider training or audits.

Expectations

This section explains specific expectations for this position and may be in addition to those expectations identified through a performance appraisal process.

• Adheres to UCM’s policies and procedures and acts in the best interest of the Organization and its patients.
• Promotes teamwork with coworkers.
• Meets or exceeds expected performance standards, including consistently reporting to work on time, prepared to perform duties of position.

• All requirements are subject to possible modification to reasonably accommodate individuals with disabilities.
• This position guide in no way states or implies that these are the only duties to be performed by the employee occupying this position.  Employees will be required to follow any other job-related instructions and to perform any other job-related duties requested by their supervisor.
• This document does not create an employment contract, implied or otherwise, other than an “at will” employment relationship.