Medical Coder

Pena4 Inc; Lawrenceville (GA); Remote; USD 70,000 - 95,000; Full time

Job summary

Pena4 Inc. is seeking an Inpatient Medical Coder (CCS certified) for a 100% remote, full-time position. The role requires at least 5 years of IP PCS coding experience and CCS certification, with OP coding experience a plus. A coding assessment will be required to qualify.

The coder will review medical records, assign accurate diagnoses and procedures, and optimize DRG assignments using ICD-10-CM/PCS, CPT, and related guidelines. Cerner, PowerChart, 3M, and EPIC experience is preferred.

Qualifications

• Minimum 5 years of IP PCS coding experience.
• Minimum 3 years of OP coding experience preferred.
• CCS certification required.
• Remote, full-time weekday schedule.
• Must complete and pass IP/OP coding assessments.

Responsibilities

• Examine the complete medical record to determine principal and secondary diagnoses, procedures, and complications.
• Accurately sequence diagnoses and procedures, maintaining 95% accuracy.
• Aim for optimal DRG assignments with computer-assisted coding.
• Maintain a steady level of productivity and quality.
• Escalate when additional information is needed for accurate codes/DRG; contact staff as needed.
• Stay current with coding guidelines and share knowledge with colleagues.
• Complete assignments as directed by management.
• Pursue continuing education and professional development.
• Work as a team member to meet department and client goals.
• Perform related duties or special projects as assigned.

Skills

IP PCS Coding

OP Coding

Coding assessment

Education

CCS Certification

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.