Inpatient Medical Coder (Remote)

Caban Resources; United States; Remote; USD 60,000 - 90,000; Full time

Job summary

Caban Resources seeks a qualified medical coder to accurately assign E/M codes, ICD-10, CPT, and related codes from clinical documentation. You will review documentation for inconsistencies and educate providers to improve coding accuracy and compliance.

Role requires certifications such as CCS, CPC, RHIT or RHIA, with additional CEMC or NAMAS CEMA a plus. Strong collaboration with auditors and CDI specialists is expected.

Qualifications

• Certification(s) in professional medical coding (CCS, CPC, RHIT or RHIA).
• CEMC or NAMAS CEMA certifications are a plus.

Responsibilities

• Assigns E/M codes, ICD-CM/ICD-10-PCS, CPT, HCPCS, modifiers and quantities from medical records for ambulatory ER and related encounters.
• Reviews documentation to identify inconsistencies or discrepancies impacting coding and patient care quality.
• Identifies issues with legibility or abbreviations and communicates with providers to resolve them.
• Educates providers and staff to resolve documentation issues and ensure coding compliance.
• Assigns accurate codes based on provider responses to coding queries; acts as a coding reference for medical staff.

Skills

Coding accuracy

Documentation feedback

Education

CCS

CPC

RHIT

RHIA

CEMC

NAMAS 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.