What are the responsibilities and job description for the Clinical Coder / Medical Records Specialist position at eTeam Inc?
Job Title : Clinical Coder / Medical Records Specialist
Location : Remote
Job Summary :
We are looking for a detail-oriented Clinical Coder / Medical Records Specialist to join our team. The successful candidate will be responsible for reviewing clinical documentation, diagnostic results, and medical records to accurately assign ICD-9-CM / ICD-10-CM / PCS and CPT-4 codes. This role plays a critical part in ensuring regulatory compliance, reimbursement, and accurate external reporting for inpatient and outpatient records.
Key Responsibilities :
- Review clinical documentation and diagnostic results to extract and abstract data, applying appropriate ICD-9-CM / ICD-10-CM / PCS and CPT-4 codes.
- Code and abstract medical records of high complexity within acute care facilities.
- Identify and assign the correct principal diagnosis, secondary diagnoses, and procedure codes in compliance with guidelines.
- Assign Present on Admission (POA), Hospital Acquired Condition (HAC), and Core Measure Indicators for all diagnosis codes.
- Facilitate appropriate MS-DRG assignment for inpatient records and APC assignment for outpatient records using UHDDS and facility guidelines.
- Use the facility encoder as it interfaces with the hospital's mainframe and / or EMR in an on-site or remote setting.
- Review charges and evaluate management levels for accuracy.
- Abstract coded data and relevant information in the hospital's electronic health records (EHR) system.
- Ensure the accuracy of data input and meet established quality and productivity standards.
- Facilitate peer review and training for all Acute Clinical Coders in the coding department.
- Stay current with coding principles and regulatory guidelines for both inpatient and outpatient coding.
- Provide support to management as needed.
Qualifications :
Work Environment :
This role may be performed in a fast-paced office environment or remotely, with daily and weekly deadlines that must be met.
If you are interested, qualified, available, planning to make a change, or know of a friend who might have the required qualifications and interest, please call me ASAP at (732) 290-4745 even if we have spoken recently about a different position. If you do respond via e-mail please include a daytime phone number so I can reach you.
