Coder/Abstraction to Outpatient

Hospital for Special Care; United States; On-site; USD 50,000 - 65,000; Part time

Benefits offered by this job

Competitive benefits package

Equal Opportunity Employer

Job summary

Hospital for Special Care is seeking a Health Information Management Coding Specialist to manage outpatient account coding and facility charges. The successful candidate will be responsible for abstracting clinical information and ensuring compliance with ICD‑10 and CPT coding guidelines.

Candidates should have an Associate’s degree in health information management, along with required certifications or the ability to achieve them within two years.

This role involves working both independently and collaboratively, ensuring timely completion of coding processes as well as supporting clinical teams with documentation practices.

Qualifications

• Minimum 3 years coding clinic/physician‑based records.
• Able to achieve certification within 2 years of hire.

Responsibilities

• Responsible for coding and facility charge process for outpatient accounts.
• Educates staff on proper documentation practices and coding guidelines.
• Works closely with clinical documentation improvement initiatives.

Skills

Ability to read, analyze, and interpret ICD‑9, ICD‑10, CPT

Ability to document and follow‑up on DNFB reports

Proficiency in Anatomy and Physiology

Understanding of denials and how to solve them

Ability to effectively describe modifiers

Education

Associate’s degree in health information management

Certified Coding Specialist (CCS)

Registered Health Information Technician (RHIT)

Tools

3M applications

EMR

Job description

Position: Health Information Management Coding Specialist. Location: Hospital for Special Care. Scheduled weekly hours: 16. Work shift: First Shift. Department: Health Information Management.

QUALIFICATIONS

• Associate’s degree in health information management or equivalent from a two‑year college. Minimum 3 years coding clinic/physician‑based records. Years of experience in coding may be considered as substitute for education.
• Certified Coding Specialist (CCS) or Certified Coding Specialist – Physician‑based (CCS-P), or Certified Professional Coder‑Payer (CPC-P), or able to achieve certification within 2 years of hire.
• Ability to read, analyze, and interpret ICD‑9, ICD‑10, CPT, HCPCS, and Modifier books.
• Ability to document and follow‑up on Discharged Not Final Billed (DNFB) reports and to effectively present information and respond to questions from Administration, Physicians, and committee members.
• Ability to effectively describe when and how to use modifiers on CPT codes to physicians and other healthcare providers.
• Understanding of denials and how to solve them.
• Proficiency in Anatomy and Physiology, Medical Terminology, and 3M applications. Past experience using 3M HDM report writer is a plus.
• Familiarity with a hybrid medical record and working with an electronic medical record.
• Experience with proper DRG assignment.
• Preferred: Experience with coding inpatient records.
• Preferred: Registered Health Information Technician (RHIT) certification is a plus.

JOB SUMMARY

Responsible for the coding and facility charge process for outpatient accounts, with occasional assistance in inpatient coding. Abstracts clinical information from medical records and assigns appropriate ICD‑10 diagnoses and procedure codes, along with CPT modifiers, per coding guidelines and established procedures. Educates medical and clinical staff on proper documentation practices, DRG assignment, modifiers, and changes in software upgrades, and communicates regulatory guideline updates. Works closely with clinical documentation improvement initiatives and patient accounts to ensure documentation accurately reflects patient acuity.

PHYSICAL DEMANDS

Requires walking, standing, and sitting with the ability to lift, carry, push, and pull weights of 11‑20 pounds frequently. Also requires squatting, kneeling, balancing, reaching forward and above shoulders, twisting, and hearing frequently. Touch, see, and manipulate continuously with gross and fine motor skills.

COGNITIVE DEMANDS

Requires solid problem‑solving, written expression and communication, thorough verbal expression, extensive reading, and auditory comprehension. Ability to perform arithmetic with units of American money, weight, volume, and distance. Ability to solve practical problems and interpret a variety of instructions in written, oral, diagrammatic, or schedule form.

WORK DEMANDS

Works independently and collaboratively. Stays current with official coding guidelines for both inpatient and outpatient coding, regulatory changes, and professional journals. Maintains continuing education for coding certification. Operates on a hybrid schedule.

ESSENTIAL FUNCTIONS

• Ensures coding processes are completed timely and efficiently on both outpatient and inpatient discharged accounts as assigned.
• Works with HIM and other staff to identify and resolve outstanding accounts through the revenue cycle.
• Uses EMR, 3M HDM abstracting, coding, and reference tools with clinical documentation tools to assign all diagnostic, procedure, and facility‑based charges in a timely manner.
• Participates on the Outpatient Revenue Cycle Committee.
• Collaborates using Coding Guru to ensure proper modifier assignment to CPT codes for inpatient and outpatient procedures or services.
• Resolves outstanding edits and denials for assigned case load weekly.
• Communicates with clinicians to resolve issues.
• Follows up with providers for any records that cannot be completed due to lack of documentation or clarification.
• Distributes coding queries as appropriate.
• Provides information and training to clinical staff and providers on coding practice changes (ICD‑10, CPT, modifiers), documentation practices, and DRG assignments as needed.
• Assists with updating departmental coding policies and procedures.
• Serves as a resource for all hospital staff with questions related to inpatient ICD‑10 coding and CPT modifiers.
• Participates in training, updates, and knowledge‑based review on utilizing the EMR to maximize coding efficiency.
• Maintains knowledge of outpatient coding practices and procedures.
• Maintains knowledge of Federal, State, and JC standards of documentation regulations and guidelines.
• Maintains and keeps coding credentials current.

We are an Equal Opportunity Employer.

We offer a competitive benefits package.