Certified Coder (24 Hours/Week)

Springfield Clinic; Springfield (IL); Hybrid; USD 55,000 - 75,000; Full time

Job summary

Springfield Clinic is seeking a professional coder to review clinical documentation and apply CPT/HCPCS and ICD-10-CM codes for services rendered in office and hospital settings. The role ensures documentation supports billed services, remains compliant with regulatory guidelines, and maintains accurate coding across professional and facility encounters.

Responsibilities include reviewing medical records, verifying codes, and communicating with physicians to obtain missing information.

Qualifications

• High School graduate or GED; college degree in health-related field preferred.
• Coding experience in Professional & Facility Coding.
• 2 years of experience as a certified coder preferred.

Responsibilities

• Review and analyze documentation in medical records for professional services (clinic, inpatient, outpatient).
• Verify and code diagnosis, evaluation and management, procedures for completeness and accuracy.
• Code and review encounters to identify first-listed diagnosis, comorbidities, complications, and procedures (ICD10, CPT, HCPCS).
• Examine documents to ensure signatures, patient identification, and adequate documentation.
• Communicate with hospitals/physicians to obtain additional documentation as needed.

Skills

CPT/HCPCS knowledge

ICD-10-CM coding

E/M leveling

Modifiers

Analytical skills

Communication skills

Customer service

Education

High School diploma or GED

College degree in health-related field preferred

AHIMA or AAPC certification (CPC/CCS/CCS-P/RHIT/RHIA)

Tools

MS Word

MS Excel

PowerPoint

Outlook

Teams

EncoderPro

Athena

Ingenious Med

RCX

Job description

This position is responsible for reviewing clinical documentation and applying the correct coding and modifiers for clinical services performed in office and/or hospital setting an may include surgical and non-surgical procedural services. This position ensures that the documentation supports the levels or types of service billed, ensures the documentation is compliant with regulatory regulations, provider documentation guidelines, and CPT documentation and CMS coding guidelines

Job Relationships

Reports to the Coding Unit Manager

Principal Responsibilities

• Responsible for reviewing and analyzing documentation present in the medical record for professional services related to clinic, inpatient and/or outpatient services.
• Verifying and coding of the diagnosis, evaluation and management, procedures or other codes required for the completeness and accuracy of the record.
• Codes and/or reviews encounters to identify first-listed diagnosis, co-morbidities, complications, therapeutic and diagnostic procedures with International Classification of Diseases (ICD10), Current Procedural Terminology (CPT), Heath Care Financing Administration Common Procedure Coding Systems (HCPCS - all levels, and any other coding classification systems that may be required).
• Examine all documents in the record for authorized signature and patient identification to ensure all documents contain sufficient documentation to support the diagnosis and treatment administered, and the results obtained are adequately described.
• Communicates with hospitals/physicians to obtain additional documentation when needed to complete coding documentation requirements.
• Responsible for charges to be posted in a timely fashion as directed by the Manager.
• Assist other staff employees as necessary including training fellow coders in specialties of expertise.
• Assist the Director or Manager with all projects in related scope of job knowledge and responsibility.
• Comply with the Springfield Clinic incident reporting policy and procedures.
• Adhere to all OSHA and Springfield Clinic training & accomplishments as required per policy.
• Provide excellent customer service and adhere to Springfield Clinic's Code of Conduct and Ethics Standards.
• Perform other job duties as assigned.

Education/Experience

• High School graduate or GED minimum required: College degree in health-related field preferred.
• Coding experience in Professional & Facility Coding
• 2 years of experience as a certified coder preferred

Licenses/Certificates

• Must have one of the following AHIMA or AAPC certifications: CPC, CCS, CCS-P, RHIT, RHIA

Knowledge, Skills and Abilities

• Expert knowledge of CPT, HCPCS, E/M leveling, Modifiers and ICD-10-CM diagnostic coding required.
• Proficient computer skills using MS-Word, Excel, PowerPoint, Outlook, Teams, Microsoft Edge, and EncoderPro.
• Preferred knowledge using Athena, Ingenious Med and RCX.
• Utilize Official Guidelines for Coding and Reporting, Coding Clinics and CPT for coding accuracy.
• Provide excellent customer service internal and external and adhere to Springfield Clinic's Code of Conduct and Ethics Standards.
• Strong analytical and communication skills.
• Attend, as directed, conferences, in-services and workshops toward further professional development and job knowledge.
• Maintain credentialing CEUs
• Follow all Clinic operation procedures and policies.

Working Environment

• In office, remote optional based off productivity/accuracy standards

PHI/Privacy Level

HIPAA1