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Senior Medical Coder
2 months ago
Position Summary
The Senior Medical Coder is responsible for the electronic documentation, organization, and reporting of extensive medical data. This role entails coding various service types based on departmental assignments, including:
- Facility Health Information Management: Inpatient, outpatient, emergency room, and outpatient clinical coding.
- Ambulatory Services: Coding and auditing for professional inpatient, outpatient, emergency, and clinic services.
Coders are expected to possess a comprehensive understanding of procedure coding, diagnosis coding, medical terminology, and anatomy/physiology. Proficiency in hospital coding includes ICD-10 PCS/DRG/CPT/HCPCS/ICD-10 CM, while professional coding proficiency covers CPT/HCPCS/ICD-10/CM.
Key Responsibilities
Collaboration
* Engage with physicians to track un-coded charts and identify opportunities for accurate coding completion.
Work closely with Clinical Documentation Improvement (CDI) specialists, healthcare providers, and clinical staff to establish and maintain a thorough audit and management system, ensuring proper charge capture, adequate documentation, and accurate code assignment across all service lines.
Provide mentorship and training to fellow coders within the department.
For the Ambulatory/Professional Team: Deliver coding and documentation education and training to providers, staff, and leadership.
Data Integrity
* Review medical records to accurately abstract code assignments.
Assign ICD-10 CM/PCS/CPT and HCPCS codes to inpatient, outpatient, emergency room, outpatient clinical, and professional services as necessary.
Utilize precise procedure coding, diagnosis coding, medical terminology, anatomy/physiology, and adhere to industry regulations.
Assist in maintaining the integrity of medical records and identifying documentation improvement opportunities.
For the Ambulatory/Professional Team: Create educational materials based on coding changes, code updates, and audit findings as required.
Compliance and Safety
* Report any safety-related incidents promptly through the designated reporting tool; participate in all safety training programs; perform duties safely; monitor the work environment for potential safety issues and ensure compliance among colleagues.
Stay informed and comply with state and federal regulations/statutes and organizational policies that affect the employee's responsibilities.
Ensure all necessary certifications and/or licenses are current and valid prior to expiration dates, if applicable for the position.
Complete all mandatory company training modules and job-specific training within the designated timeframe.
Maintain confidentiality regarding all departmental, patient, and coding matters.
Stay updated with medical terminology and human anatomy.
Meet industry standards for productivity and accuracy.
Qualifications
Education
High School Diploma or GED - Required
Associate's Degree or Diploma from a recognized program - Preferred
Certifications & Licenses
CPC/CSS/CCA/RHIT/RHIA/CPMA - Required
Experience
Minimum of 2 years - Required
Proficiency in ICD-10 - Required
As healthcare evolves rapidly, technology is integrated into nearly all facets of patient care. Proficiency in using computers and basic software programs is essential.