Inpatient Facility Medical Coder

3 weeks ago

Clackamas, United States HR Recruiting Services Full time
Job DescriptionJob Description

This is a remote position.

Seeking a detail-oriented coder to assign diagnosis accurately and procedure codes for various healthcare settings including Emergency Department, Ambulatory Surgical Center, Hospital Ambulatory Surgical Center, Observations, and Inpatient records. Must maintain high standards of quality and productivity. Ability to communicate effectively with physicians for clarification and understand clinical content for data abstraction.

In this position:
  • Assign accurate diagnosis and procedure codes to patient health records for various facility settings
  • Maintain acceptable levels of quality and productivity in ICD-10-CM, ICD-10-PCS, and HCPCS/CPT coding systems.
  • Adhere to coding guidelines established by CMS, NCHS, AMA, NCCI, UHDDS, OMAP
  • Communicate with physicians to clarify diagnoses and procedures as needed.
  • Abstract clinical data from health records and perform other assigned duties.
  • On-site training required for one (1) week or until department expectations are met.

Responsibilities:

  • Review medical records and assign appropriate codes for diagnoses, procedures, and services rendered.
  • Validate Computer Assisted Coded (CAC) assignments for accuracy.
  • Utilize Code Base Charge Trigger system (CBCT) and EncoderPRO software for coding professional surgical services.
  • Abstract clinical data elements and ensure accurate sequencing of diagnosis and procedure codes.
  • Perform chart analysis to identify incomplete or inaccurate documentation.
  • Maintain department standards for productivity and quality.
  • Stay updated on coding guidelines and regulations.


RequirementsQualifications:
Candidates must reside either in Washintgon or Oregon to be considered.
Minimum five (5) years experience in coding with four (4) years inpatient facility coding Advanced knowledge of medical terminology, pharmacology and medial coding principles for ICD-10-CM, ICD-10-PCS, HCPCS/CPT and coding. Advance knowledge of disease processes, diagnostic and surgical procedures, ICD-10-CM, ICD-10-PCS, HCPCS/CPT classification systems, health information/medical record department responsibilities with knowledge of government regulations and areas of scrutiny for potential fraud and abuse issues.

Additional Requirements
  • Previous experience with EMR patient documentation system with intermediate knowledge and skill in the use of a computer.
  • Fluent in English, demonstrating skill and proficiency in oral and written communication.
  • Time management, organization and analytical skills.
  • Ability to manage a significant workload and to work efficiently under pressure meeting established deadlines with minimal supervision.
  • Abides by the Standards of Ethical Coding as set for by the American Health Information Management Association (AHIMA).
  • Pass a coding skill test with a 75% or better.
  • Academic knowledge and working experience performing coding and abstracting responsibilities in health information/medical record services.
  • The position requires the new coder to be on-site for one (1) week of training or until they meet the department expectations.

Preferred Qualifications:
  • Minimum five (5) years of experience in health information/Medical record environment, with facility coding experience that includes Medicare reimbursement guidelines.
  • Degree in Health Information Management.
  • Proficient knowledge and skill in the use of a computer and related system and software to include: EMR(s), Microsoft Office Suite and other software programs.
  • Ability to evaluate, analyze, develop information regarding mathematical statistics and percentages that compare finding trends and outcomes related to productivity and /ore medical record audits.
  • Extensive knowledge of ICD-10 coding guidelines; with knowledge and demonstrated understand of CMS HCC Risk Adjustment coding and data validation requirements.
Education
  • High School Diploma or General Education Development (GED) required.

License, Certification, Registration

Must have 1 from the following list:

  • Registered Health Information Technician Certificate
  • Coding Specialist Certificate
  • Registered Health Information Administrator Certificate



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