Outpatient Medical Coder (Remote)

Caban Resources; Florida; Remote; USD 60,000 - 80,000; Full time

Benefits offered by this job

Job summary

Caban Resources in Florida seeks a certified medical coder to assign E&M, ICD-10-CM/PCS, CPT, and HCPCS codes from clinical documentation for ambulatory encounters.

You will review records for accuracy, identify documentation gaps, educate providers, and collaborate with CDI specialists to ensure coding compliance and high-quality patient care. Experience with auditing and coding queries is preferred, and strong CPT/ICD knowledge and HIPAA compliance are required.

Qualifications

• Certification: one of CCS, CPC, RHIT, RHIA, or CCS-P.
• CEMC or NAMAS CEMA certification is a plus.

Responsibilities

• Assign E&M codes, ICD-CM diagnoses, ICD-10-PCS, CPT, HCPCS, modifiers, and quantities from documentation for ambulatory ED and related encounters.
• Review encounter/documentation to identify inconsistencies or discrepancies impacting coding and quality of care.
• Identify legibility/abbreviation issues and notify the provider.
• Educate providers and staff to resolve documentation issues to support coding compliance.
• Assign codes based on provider responses to coding queries.
• Serve as reference for medical staff on coding questions and provide examples of coding/documentation guidance; collaborate with auditors, trainers, and CDI specialists.
• Support coding compliance by researching and interpreting guidance and seeking clarifications.
• With supervisor direction, use computer systems to access patient records remotely and assign codes.
• Aim to achieve and maintain coding productivity and accuracy standards.

Education

CCS

CPC

RHIT

RHIA

CCS-P

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), Registered Health Information Administrator (RHIA), or Certified Coding Specialist – Physician (CCS-P)
• 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.