United States onlyEssential Job Functions
- Responsible for abstracting, coding, sequencing, and interpreting clinical information from inpatient, outpatient, emergency department, pro-fee, and clinical medical records.
- Responsible for assigning correct principal diagnoses, secondary diagnoses, and principal procedure and secondary procedure codes with attention to accurate sequencing.
- Utilizes technical coding principals and DRG/APC reimbursement expertise to assign appropriate codes.
- Abstracts and codes pertinent medical data into multiple software programs and/or encoders. Follows official coding guidelines to review and analyze health records.
- Maintains compliance with external regulatory and accreditation requirements as well as state and federal regulations.
- Extract pertinent data from the patient’s health record and determine appropriate coding for reports and billing documents.
- Identifies codes for reporting medical services and procedures performed by physicians. Enters codes into various computer systems dependent upon the various clients.
- Track and document productivity in specified systems and maintain productivity levels as defined by the client.
- Maintain a 95% quality rating.
- Perform duties in compliance with the Company’s policies and procedures, including but not limited to those related to HIPAA and compliance.
TITLE: Coder – Hospital Inpatient
DURATION: 13 weeks
LOCATION: fully remote
JOB SUMMARY: Responsible for coding and abstracting inpatient accounts in accordance with coding guidelines.
RESPONSIBILITIES:
• Assigns accurate diagnostic and procedure codes according to clinical documentation and official coding guidelines for inpatient hospital accounts.
• Coordinates with the clinical documentation and quality teams to ensure validation of Medicare Severity Diagnosis Related Group (MSDRG), patient safety indicators, and hospital acquired conditions are supported by physician documentation to support appropriate coding
• Monitors assigned work queues to ensure all records are charged in a timely matter.
• Generates coding queries for clarification regarding physician documentation as needed
• Stays abreast of all changes in coding conventions and coding updates.
• Performs other duties as assigned.
MINIMUM REQUIREMENTS:
• Education: Associates Degree or equivalent experience
• Certifications:
o Certified Coding Associate (CCA) - American Health Information Management Assoc (AHIMA)
o OR Certified Coding Specialist - Physician-based (CCS-P) - American Health Information Management Assoc (AHIMA)
o OR Certified Outpatient Coder (COC) - American Academy of Professional Coders (AAPC)
o OR Certified Professional Coder (CPC®) - American Academy of Professional Coders (AAPC)
o OR Registered Health Information Administrator (RHIA) - American Health Information Management Assoc (AHIMA)
o OR Registered Health Information Technician (RHIT) - American Health Information Management Assoc (AHIMA)
