Health Information Management Sr Coder

CommonSpirit Health; United States; On-site; USD 41,000 - 60,000; Full time

Job summary

CommonSpirit Health seeks a Health Information Management Senior Coder to translate medical records into ICD-10-CM, CPT, and HCPCS codes for inpatient, outpatient, and professional services. The role emphasizes accuracy, regulatory compliance, and collaborative communication with providers and staff.

The position requires CAHIIM/AHIMA/AAPC accredited coding education and at least three years of coding experience, with EMR and encoder experience.

Qualifications

• High School Diploma required.
• CAHIIM/AHIMA/AAPC Accredited Coding Education plus 3 years coding experience across inpatient, outpatient, and physician clinics.
• Experience using ICD-10-CM, CPT, HCPCS, and/or ICD-10-PCS coding.

Responsibilities

• Code inpatient, outpatient, and professional encounters with ICD-10-CM, CPT, HCPCS.
• Ensure coding accuracy and compliance with coding guidelines and payer requirements.
• Identify documentation gaps and query providers for clarification.
• Maintain confidentiality and meet productivity/turnaround targets.
• Participate in professional development and contribute to workflow improvements.

Education

CAHIIM/AHIMA/AAPC Accredited Coding Education

High School Diploma

Tools

EMR experience

Encoder experience

Job description

Health Information Management Sr Coder

Inspired by faith. Driven by innovation. Powered by humankindness. CommonSpirit Health is building a healthier future for all through its integrated health services. As one of the nation's largest nonprofit Catholic healthcare organizations, CommonSpirit Health delivers more than 20 million patient encounters annually through more than 2,300 clinics, care sites and 158 hospital-based locations, in addition to its home-based services and virtual care offerings.

The posted compensation range of $29.44 - $43.79/hour is a reasonable estimate that extends from the lowest to the highest pay CommonSpirit in good faith believes it might pay for this particular job, based on the circumstances at the time of posting. CommonSpirit may ultimately pay more or less than the posted range as permitted by law.

As a Senior Coder, you will ensure precise communication with insurance companies so that services are documented correctly and payments are processed efficiently. Every day you will accurately translate patients' medical records into standardized codes for diagnoses and treatments. Using your expertise and training, you will ensure compliance with legal, regulatory, and organizational standards. To be successful in this role, you must combine accuracy and attention to detail with a strong knowledge of coding standards and healthcare regulations. Clear communication with providers and staff, along with efficient management of records, ensures claims are processed correctly and on time.

Core Coding & Data Integrity: Applies expert-level knowledge to accurately assign and sequence ICD-10-CM, CPT, and HCPCS codes to outpatient medical records and encounters. Ensures coding decisions are fully substantiated by medical record documentation and adhere to official coding guidelines, payer requirements, and the Standards of Coding Ethics. Analyzes APCs (Ambulatory Payment Classifications) and modifier assignments to ensure thorough and compliant coding and charging, utilizing designated coding applications and systems to accurately code and abstract all assigned encounters.

Documentation Review & Integrity: Identifies conflicting, ambiguous, or incomplete documentation within medical records and initiates appropriate physician queries to obtain necessary clarifications. Works collaboratively with providers and other departments to ensure accurate and complete clinical documentation and resolve charge discrepancies.

Productivity, Quality & Confidentiality: Reviews assigned work queues, prioritizing and coding all assigned encounters within established department productivity and turnaround time frames, consistently meeting quality and accuracy standards set by Coding Leadership. Complies with all applicable laws, rules, regulations, and organizational policies, including reporting suspected violations. Maintains strict patient, medical record, department, and employee confidentiality at all times. Actively participates in professional development, fulfilling continuing education requirements and maintaining professional credentials. Contributes to a positive team environment and fosters effective communication with colleagues and leadership.

Professional Development & Departmental Contribution: May assist with new hire on boarding, provide mentorship, contribute to audit processes, and various reports. Performs other duties as assigned. Offers insights and suggestions for enhancing coding work flows, efficiency, and documentation improvement initiatives based on daily coding experience. Provides feedback on proposed coding policies and procedures, utilizing expert knowledge to identify potential impacts on coding accuracy or workflow. Offers guidance and shares expertise with less experienced coders on challenging cases or coding complexities, under the direction of leadership and without formal supervisory responsibility. Actively participates in departmental meetings, contributes to a positive team environment, and fosters effective communication with colleagues and leadership.

Required: High School Graduate. Other Completion of a CAHIIM Approved AHIMA/AAPC Accredited Coding Education and 3 years Coding Experience (Inpatient, Outpatient, Professional Fee, &/or Outpatient Physician Clinics) using ICD-10-CM, CPT, HCPCS, and/or ICD-10-PCS coding. Electronic Medical Record (EMR) and encoder experience and Certified Professional Coder, Certified Coding Specialist, Certified Coding Specialist - Physician Based, Certified Professional Coder Hospital, Registered Health Information Administrator, Registered Health Information Technician.

Preferred: Remote work experience.