Medical Coder

Pena4 Inc; City of Syracuse (NY); Remote; USD 70,000 - 100,000; Full time

Job summary

Pena4 Inc is seeking an Inpatient Medical Coder (CCS certified) to join our remote coding team. The role emphasizes accurate IP/OP coding with ICD-10-CM/PCS, HCPCS CPT, and DRG assignments, while ensuring high-quality documentation and compliance.

The candidate will review complete medical records, assign principal and secondary diagnoses and procedures, and collaborate with clinical staff to resolve coding questions.

Qualifications

• CCS certification required.
• 5+ years IP PCS coding experience.
• 3+ years OP coding experience preferred.
• Remote position (100% remote).
• W2 regular employment, full-time hours.

Responsibilities

• Examine complete medical records to determine principal and secondary diagnoses and procedures.
• Sequence diagnoses and procedures with aim of 95% accuracy.
• Maximize DRG assignments with guidance from computer systems.
• Maintain consistent productivity and quality levels.
• Hold accounts when more information is needed and coordinate with staff as required.
• Stay current with coding guidelines and share updates with colleagues.
• Complete assignments as directed by management with reliability.
• Pursue continuing education opportunities.
• Collaborate with team to meet department and client goals.
• Perform related duties or special projects as assigned.

Tools

Cerner

PowerChart

3M

EPIC

Job description

Inpatient Medical Coder (CCS certified)

Assignment Details:

• 100% REMOTE
• Position Type: W2 Regular Employment
• At least 5 years of IP PCS Coding experience, required
• At least 3 years OP, preferred
• CCS certificate is required.
• Schedule: Weekdays, full-time hours
• Shift: Regular day shift hours
• System Experience: Cerner | Power Chart | 3M | EPIC
• Start Date: Immediately
• To be considered, IP and/or OP assessment test will be required to complete and pass a coding assessment test.

Summary

IP/OP Coding Specialist demonstrates proficiency in coding all types of inpatient and outpatient accounts.

Utilizes International Classification of Disease (ICD-10-CM and PCS), Healthcare Common Procedure Coding System (HCPCS) including Current Procedural Terminology (CPT) and other coding references to ensure accurate coding.

Responsibilities:

• 1. Examines the complete medical record to accurately determine the principal & secondary diagnoses, procedures, and complications.
• 2. Accurately sequences diagnoses & procedures, maintains 95% accuracy.
• 3. Strives to obtain the optimal DRG assignments on each record coded with assistance of computer system.
• 4. Demonstrates a consistent level of performance; strives to maintain a steady level of productivity and quality.
• 5. Appropriately holds accounts when more information is required for accurate code/DRG assignment. Contact appropriate staff, leadership, or medical staff as needed.
• 6. Regularly reviews coding literature, keeps current on new or revised coding guidelines, shares information with colleagues, determined by colleagues’ feedback and supervisor observation.
• 7. Completes all assignments as directed by management in a conscientious and reliable manner.
• 8. Expresses interest in and pursues continuing education.
• 9. Works as a team member to meet department and client specific goals.
• 10. Performs all related duties or special projects as assigned/required.

This description is not intended to contain an exhaustive list of duties and responsibilities that the coder may be required to complete. There may be other duties as assigned.