Coder III | Health Information Management | Full-time | Days REMOTE

University of Florida Health; Orlando (FL); Remote; USD 10,000 - 60,000; Full time

Job summary

An established industry player is seeking a skilled Coder III to join their team. This full-time position involves assigning accurate ICD-10 codes to inpatient medical records and ensuring coding compliance with regulatory guidelines. The ideal candidate will have extensive experience in medical record coding, possess a Certified Coding Specialist (CCS) certification, and demonstrate a strong ability to collaborate with physicians to enhance documentation practices. This role offers the opportunity to work remotely while contributing to the improvement of healthcare documentation standards in a supportive environment.

Qualifications

• 5 to 7 years of experience in Hospital Medical Record Coding.
• Must have Certified Coding Specialist (CCS) certification.

Responsibilities

• Assign correct ICD-10 codes to diagnoses and procedures in medical records.
• Review medical records for coding specificity and accuracy.
• Maintain knowledge of coding guidelines and regulations.

Skills

ICD-10-CM Coding

Medical Record Review

Documentation Assessment

Encoder Knowledge

Communication with Physicians

Education

High School Diploma/Equivalent

Graduate of Health Information Management Program

Tools

Sunrise Record Manager

Job description

Overview

Full-time Monday through Friday 8:00am to 4:30pm

Remote (must live in Florida).

The Coder III position assigns diagnoses and procedure codes to inpatient medical records.

Responsibilities

• Assigns correct ICD-10-CM code to all diagnoses and correct ICD-10 PCS code to all procedures documented in the medical record.
• Thoroughly reviews the entire medical record in order to retrieve proper documents (i.e. discharge summary, progress notes, operative report, pathology report, anesthesia report, etc.) to provide coding specificity.
• Assesses documentation to ensure it is adequate and appropriate to support the diagnoses and procedures to be abstracted.
• Selects the principal diagnosis and procedure according to the Uniform Health Data Discharge Set definitions and coding rules published in Coding Clinic.
• Sequences codes within regulatory guidelines for correct DRG assignment.
• Accurately abstracts attending and operating physicians in the Sunrise Record Manager abstracting system.
• Verifies and corrects appropriate discharge disposition.
• Maintains a thorough knowledge of the use of the encoder to assist in code assignment.
• Queries physicians as necessary to resolve documentation discrepancies. Maintains a positive working relationship with physicians in order to improve coder clinical competency and educate the clinician on documentation practice issues.
• Maintains a thorough knowledge of the prospective payment system and any new codes or DRG’s added/changed each year. Adheres to all official guidelines as approved by the Cooperating Parties (AHA, AHIMA, CMS, NCHS) as well as the ICD-9-CM coding conventions, Coding Clinic, and other official resources to substantiate the most appropriate, correct code assignment. Stays abreast of Medicare’s medical review policies and incorporates updates and changes into the coding process.

Qualifications

Education / Training

• High School Diploma/Equivalent

Preferences:

• Graduate of Health Information Management Program

Experience Requirements

• 5 to 7 years Hospital Medical Record Coding

Certificates/Licenses/Registration

• Certified Coding Specialist (CCS)

Additional Information: Certified Coding Specialist (CCS) certification by AHIMA required.