We are seeking a highly skilled and motivated Medical Coder to join our team. In this role, you will independently and efficiently assign accurate diagnosis and procedure codes to patient health information records for various settings including the Emergency Department (ED), Ambulatory Surgical Center (ASC), Hospital Ambulatory Surgical Center (HAS), Observations (OBS), and Inpatient (IP) among others. Your work will adhere to the highest standards as established by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), as well as other relevant guidelines.
You will play a key role in maintaining quality and productivity in ICD-10-CM, ICD-10-PCS, and HCPCS/CPT classification and nomenclature systems. Effective communication with physicians to clarify diagnoses and procedures is essential. You should have a solid understanding of the clinical content of health records to accurately abstract and enter data. This position requires a new coder to be on-site for one week of training or until departmental expectations are met.
Essential ResponsibilitiesMedical Record Review: Expertly review medical records and translate clinical information into coded data. Assign appropriate codes for diagnoses, procedures, and services, validating Computer Assisted Coding (CAC) assignments.
Code Base Charge Trigger System: Use the CBCT and OPTUM 360 EncoderPRO software systems for professional surgical services. Ensure the accuracy, validity, and meaningfulness of these systems for both professional and facility services.
Electronic Systems Utilization: Access patient encounter information using electronic patient data systems and clinical information systems (EpicCare). Abstract and enter clinical data elements as required.
Coding and Sequencing: Identify and assign principal diagnosis and procedure codes, ensuring correct sequencing for Ambulatory Payment Classification (APC), Medicare Severity-Drug Related Group (MS-DRG), and All Patients Refined Diagnosis Related Groups (APR-DRG) assignment.
Chart Analysis: Perform regular chart analysis to identify incomplete, inaccurate, or inconsistent documentation. Review and verify chart information and ensure diagnostic and therapeutic procedures conform to CMS coding rules and guidelines.
Research and Query: Use resources like Coding Clinic and CPT Assistant to research and apply coding guidelines. Address coding concerns and utilize the query process when needed. Implement solutions to reduce coding errors.
Continuous Learning: Stay updated on coding and regulatory changes by attending workshops and reviewing publications. Participate in team meetings, coding in-services, and national and regional coding education sessions.
Team Collaboration: Maintain confidentiality and effective working relationships with staff. Communicate clearly and exercise independent judgment. Participate in the development of organizational procedures and special projects as assigned.
QualificationsBasic Qualifications:
Minimum of two years' experience in a related coding field or 18 months within an apprentice program.
High School Diploma or General Education Development (GED) required.
One Of The Following Certifications Is RequiredRegistered Health Information Technician (RHIT)
Registered Health Information Administrator (RHIA)
Certified Coding Specialist (CCS)
Job Type: Contract
Pay: $24.71 - $35.76 per hour
Benefits401(k)
Dental insurance
Health insurance
Life insurance
Paid time off
Vision insurance
Work Setting: Remote
Experience: ICD-10: 1 year (Preferred)
Work Location: In-person training required for the first week or until expectations are met.
We look forward to welcoming a dedicated professional to our team who is passionate about maintaining the highest standards in medical coding. If you meet the qualifications and are excited about the opportunity, we encourage you to apply.
Employment Type: Contractor