Responsible for assigning and validating diagnostic and procedural codes for outpatient charts using ICD-10 and CPT systems. Ensures compliance with coding regulations and medical necessity guidelines while maintaining accurate documentation.
Requirements summary
Requires one to three years of acute care medical coding experience and a relevant professional certification such as RHIA, RHIT, CCS, or CPC. Proficiency in EMR systems and 3M encoder software is essential for this role.
high schoolassociate degreebachelor degreeMicrosoft OfficeCPTCommunication skillsHCPCSTime managementICD-10-CMICD-10-PCSMedical codingElectronic medical record3M encoderUHDDS guidelinesCCI editsCDI toolsCoding clinic
Job description
Acute Surgery Coder
You must reside in one of these states to be eligible for this position
Arkansas California Kentucky Massachusetts Nevada New Mexico Oregon Utah Tennessee Texas Wyoming
Employment Type
Full
Time
Location:
Remote
Reports To: Coding Operations Manager
Job Summary
Responsible for assigning appropriate diagnostic and procedural codes to patient charts of moderate to high complexity using ICD-10-CM, ICD-10-PCS, CPT, HCPCS or any other designated coding classification system in accordance with coding rules and regulations. Abides by the Standards of Ethical Coding as set forth by AHIMA.
The Outpatient Coder shall review hospital outpatient medical documentation or physician medical record documentation to assign, sequence, edit and/or validate the appropriate ICD-10-CM, CPT and HCPCS codes with outpatient encounters to ensure proper coding, billing and compliance.
Will match outpatient coding area to experience (i.e. Same Day Surgery, Routine Outpatient, Physician, Recurring, Observation, etc.)
Reviews encounter to assign and sequence appropriate diagnoses and/or procedure codes as well as modifiers to diagnostic, physician and/or surgical encounters in accordance with Official Coding Guidelines, CMS regulations, Local Medical Review Policy (LMRP), guidance in encoder software and HIM coding policies and procedures
Using 3M encoder, reviews Ambulatory Payment Classifications (APC) and coding edits. Reviews Local/National Coverage Determination (LCD/NCD) edits and guidance for codes meeting medical necessity. Research electronic medical record for any additional diagnoses documented to meet medical necessity.
Ability to assign Physician E/M levels and charges for all relevant procedures performed in various settings, if applicable.
Ability to assign injections and infusions, if applicable.
Qualifications
One to three years’ experience performing medical record coding in acute care setting required.
High school diploma or equivalent is required.
Associate of bachelor’s degree in Health Information, Nursing, or other related field, or formal coding classes completed and passed preferred. Years of coding experience will be considered in lieu of educational requirements.
Benefits
Flexible scheduling
Paid time off
Competitive salary
Retirement savings plan
Professional development
Healthcare coverage
Student loan repayment program
Functional Knowledge of EMR (Electronic Medical Record), Encoder and CDI Tools and other Support Software.
Comprehensive understanding of UHDDS guidelines, CCI Edits, Coding Clinic, etc.
Microsoft Office (Word, One Note, Excel, Outlook, PowerPoint) proficient.
Excellent verbal and written communication skills.
Ability to meet assigned deadlines.
Work Experience, Education, and Certifications
Associate degree preferred.
1 year of Acute/Physician Coding Experience.
AHIMA or AAPC Certification required such as RHIA, RHIT, CCS, CPC, CIRCC, COC
Software/Hardware
• 3M360 experienced required.
Benefits
Competitive salary and benefits package.
Opportunities for professional development and advancement.
Supportive work environment with a collaborative team.
