Inpatient Medical Coder (Remote)

CABAN RESOURCES, LLC; Florida; Remote; USD 55,000 - 75,000; Full time

Job summary

Caban Resources is seeking a medical coder to accurately assign E/M codes, ICD codes, CPT/HCPCS, and related quantities from clinical records for ambulatory emergency services. The role requires holding CCS, CPC, RHIT, or RHIA certification, with CEMC or CEMA considered a plus.

The ideal candidate will review documentation, resolve discrepancies, educate providers on documentation standards, and collaborate with coding auditors and CDI specialists to ensure coding accuracy and compliance.

Qualifications

• Certification: ONE of the following recognized professional coding certifications: CCS, CPC, RHIT, or RHIA.
• CEMC or NAMAS's CEMA certifications are a plus.

Responsibilities

• Accurately assigns E/M codes, ICD-CM diagnoses, ICD-10-PCS, CPT, HCPCS, modifiers, and quantities from medical records for professional and facility components of ambulatory emergency room.
• Reviews encounter documentation to identify and resolve inconsistencies or discrepancies affecting coding accuracy and patient care.
• Identifies legibility or abbreviation issues and notifies providers.
• Educates providers and staff to resolve documentation issues and support coding compliance.
• Assigns accurate codes based on provider responses to coding queries.
• Acts as a reference for medical staff on coding questions and collaborates with auditors, trainers, and CDI specialists.
• Researches and interprets guidance to support coding compliance.

Education

CCS

CPC

RHIT

RHIA

CEMC

CEMA

Job description

Minimum Qualifications

• Certification: ONE of the following recognized professional coding certifications: Certified Coding Specialist (CCS), Certified Professional Coder (CPC), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA)
• Certified Evaluation and Management Coder (CEMC), or National Alliance of Medical Auditing Specialists' (NAMAS) Certified Evaluation and Management Auditor (CEMA) certifications are a plus.

Core Duties

• Accurately assigns Evaluation and Management (E/M) codes, International Classification of Diseases, Clinical Modification (ICD-CM) diagnoses, ICD-10 Procedure Coding System (ICD-10-PCS), Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), modifiers, and quantities derived from medical record documentation for the professional and facility components of ambulatory emergency room. May also code ambulatory or outpatient encounters as directed.
• Reviews encounter and/or record documentation to identify and resolve inconsistencies, ambiguities, or discrepancies that may cause inaccurate coding, and impacts to quality patient care.
• Identifies any problems with legibility, abbreviations, etc., and brings to the provider's attention.
• Educates and provides feedback to providers and clinical staff to resolve documentation issues to support coding compliance.
• Assigns accurate codes to encounters based upon provider responses to coding queries.
• Acts as a source of reference to medical staff having questions, issues, or concerns related to coding. Responds to provider questions and provides examples of appropriate coding and documentation reference(s) to provide clarity and understanding. Collaborates with and supports medical coding auditors, trainers, and CDI specialists in providing education and feedback to providers and staff.
• Supports coding compliance by ethically and appropriately researching and/or interpreting existing guidance, including seeking clarification through appropriate channels.
• Upon coding supervisors' direction, utilizes computer systems to remotely access patient records and assign codes for patient encounters.
• Achieve and maintain coding productivity and accuracy standards for the position.