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Medical Coding Specialist for Outpatient Facilities
2 months ago
The role involves independently and effectively executing the responsibilities of assigning precise diagnosis and procedure codes to patient health information records across various settings, including Emergency Departments, Ambulatory Surgical Centers, and Inpatient records. The coder is expected to maintain a satisfactory level of performance in terms of quality and productivity, adhering to ICD-10-CM, ICD-10-PCS, and HCPCS/CPT classification systems. All tasks will be conducted in compliance with established coding guidelines from authoritative bodies such as the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA).
Key Responsibilities:Demonstrate proficiency in reviewing medical records and converting clinical information into coded data. Accurately identify and assign codes for diagnoses and procedures, while also validating Computer Assisted Coding (CAC) assignments. Utilize coding software systems effectively to ensure accuracy and compliance with applicable coding conventions.Conduct thorough chart analyses to pinpoint areas of incomplete or inconsistent documentation. Review and verify medical record components to ensure they meet CMS coding standards and maintain departmental productivity and quality benchmarks.Utilize available resources, such as Coding Clinic and CPT Assistant, to resolve coding issues and implement solutions to minimize coding errors. Stay informed on coding regulations and attend educational sessions to remain updated on industry trends and compliance requirements.Participate in special projects as needed while maintaining confidentiality and fostering effective working relationships with colleagues. Communicate clearly and exercise independent judgment in all coding-related tasks.Qualifications:
Minimum of two years of experience in a relevant coding field or 18 months within a recognized coding apprenticeship program.High School Diploma or equivalent required.Certification from one of the following: Registered Health Information Administrator, Registered Health Information Technician, or Certified Coding Specialist.Additional Skills:
Experience with electronic medical record systems and strong computer skills.Advanced understanding of medical terminology, coding principles, and relevant regulations.Ability to manage a significant workload efficiently and meet deadlines with minimal supervision.Adherence to ethical coding standards as defined by the American Health Information Management Association (AHIMA).Willingness to undergo a coding skills assessment as part of the selection process.Preferred Experience:
Two years of experience in a health information or medical record environment, with specific facility coding experience.Proficiency in using various software programs, including EMR systems and Microsoft Office Suite.Extensive knowledge of ICD-10 coding guidelines and risk adjustment coding.Degree in Health Information Management is advantageous.
