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

UF Health; Saint Augustine (FL); Remote; USD 50,000 - 80,000; Full time

Job summary

An established industry player is seeking a detail-oriented Coder III to join their team. This role involves coding inpatient medical records with accuracy and specificity, ensuring compliance with official guidelines and regulations. The ideal candidate will have a strong background in medical record coding, excellent communication skills, and the ability to work collaboratively with physicians. This position offers the opportunity to make a significant impact in healthcare documentation while working remotely within Florida. If you are passionate about coding and eager to contribute to a vital aspect of patient care, this opportunity is perfect for you.

Qualifications

• 5-7 years of experience in Hospital Medical Record Coding required.
• CCS certification by AHIMA is mandatory.

Responsibilities

• Assign ICD-10-CM and ICD-10 PCS codes to inpatient medical records.
• Review medical records for documentation and coding specificity.
• Maintain knowledge of coding guidelines and regulations.

Skills

ICD-10-CM Coding

Documentation Review

Coding Specificity

DRG Assignment

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.