Certified Medical Records Coder

AAPC; Dallas (TX); On-site; USD 50,000 - 65,000; Full time

Job summary

Children’s Health seeks a Certified Medical Records Coder to accurately assign ICD-10-CM and CPT codes for ED, radiology, and outpatient encounters. Proficiency with encoder software and code books is required, with hospital experience preferred.

The role includes reviewing records, determining diagnosis sequences, assigning infusion codes, and ensuring complete data capture for discharge data. Equal opportunity employer and holistic benefits apply.

Qualifications

• Review and assign ICD-10-CM and CPT codes to ED, radiology and outpatient records.
• Abstract patient information and forward reports as required.
• Utilize encoder software and/or code books to assign accurate diagnoses.
• Determine sequence of diagnoses for hospital discharge data.
• Review CPT infusion codes following infusion guidelines.

Responsibilities

• Maintain departmental policies and quality standards.
• Assist in training hospital personnel in coding procedures.
• Retrieve records for closing out each month and correct coded data as required.
• Query physicians for clarification when information is incomplete.
• Ensure proper data items are recorded (attending physician, discharge disposition, etc.).

Skills

ICD-10-CM coding

CPT coding

Medical records review

Computer skills

Education

High School

Certified Coding Specialist (CCS) / CPC / CCA certifications

RHIA/RHIT (optional)

Tools

Encoder software

Solventum encoder

Epic encoder experience

Code books

Job description

Certified Medical Records Coder

This job is responsible for accurately assigning diagnostic (ICD-10-CM), procedure (CPT), and infusion codes to records of emergency department, radiology, and other outpatient encounters and facility settings as assigned, abstracting patient information, and forwarding reports as required. Epic and Solventum encoder experience preferred.

Responsibilities:

• Maintain established departmental policies and procedures, objectives, quality assurance program, safety, environmental and infection control standards.
• Possess in-depth knowledge of the conventions, rules, and guidelines of multiple classification systems, including ICD-10 diagnosis and procedures and Current Procedural Terminology (CPT).
• Possess in-depth knowledge of disease process in multiple medical/surgical specialties.
• Review patients' entire current medical records and utilize encoder software and/or code books to assign appropriate diagnosis codes using the International Classification of Diseases, 10th Edition – Clinical Modification (ICD-10-CM) according to predetermined department standards.
• Determine the sequence of diagnoses according to uniform hospital discharge data.
• Review and assign CPT infusion codes following guidelines for infusion administration.
• Review surgical and designated diagnostic procedure documentation to assign appropriate procedure codes using the International Classification of Diseases, 10th Edition, Procedure Coding System (ICD-10_PCS), and Current Procedural Terminology (CPT) using encoder software and/or code books.
• Determine and record other required data items such as attending physician, discharge disposition, number of consultations, referral source, and similar data.
• Query physicians or other providers to obtain clarification and diagnosis information when not recorded on discharge, or if information is incomplete.
• Assist in training hospital personnel in coding procedures.
• Assist in care and maintenance of department equipment and supplies; maintain department records, reports and files as required.
• Participate in educational programs and in-service meetings; attend other meetings as required.
• Retrieve records for closing out each month and make corrections to coded and abstracted information as required.

How You'll Be Successful:

• WORK EXPERIENCE: At least 1 year hospital experience Preferred
• Computer skills Required
• EDUCATION: High School Essential
• LICENSES AND CERTIFICATIONS: Certified Coding Specialist-2P-CCS Essential Certification as Certified Coding Specialist (CCS), Certified Coding Associate (CCA), Certified Professional Coder (CPC), Certified Professional Coder Apprenticeship (CPC-A), Certified Professional Coder-Hospital (CPC-H), Certified Outpatient Coder (COC), Certification as Registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT) - Time Frame: Upon Hire

A Place Where You Belong

We put our people first. We welcome, value, and respect the beliefs, identities and experiences of our patients and colleagues. We are committed to delivering culturally effective care, creating meaningful partnerships in the communities we serve, and equipping and developing our team members to make Children's Health a place where everyone can contribute.

Holistic Benefits – How We'll Care for You:

Employee portion of medical plan premiums are covered after 3 years.

4%-10% employee savings plan match based on tenure

Paid Parental Leave (up to 12 weeks)

Caregiver Leave

Adoption and surrogacy reimbursement

As an equal opportunity employer, Children's Health does not discriminate against employees or applicants because of race, color, religion, sex, gender identity and expression, sexual orientation, age, national origin, veteran or military status, disability, or genetic information or any other Federal or State legally-protected status or class. This applies to all aspects of the employer-employee relationship including but not limited to recruitment, hiring, promotion, transfer pay, training, discipline, workforce adjustments, termination, employee benefits, and any other employment-related activity.