Profee & Facility Coder - Emergency Medicine

Brault; San Dimas (CA); On-site; USD 55,000 - 75,000; Full time

Job summary

Brault is seeking a Medical Coding Specialist to assign CPT and ICD-10 codes to patient records, review documentation for accuracy, and provide feedback to physicians for documentation improvement. The role emphasizes high-volume coding with strict accuracy and adherence to Brault policies and regulatory requirements.

Qualifications include CPC/CCS-P credentials and 3+ years in E/M and CPT coding, with experience in EHR systems and billing platforms.

Qualifications

• Requires CPC or CCS-P credential by an accredited program.
• Minimum three years of E/M and CPT coding experience.
• Experience with EHR systems and billing platforms; proficient in Microsoft Office.

Responsibilities

• Code CPT and ICD-10 codes for patient records in line with Brault policies and payer requirements.
• Review documentation to identify opportunities for documentation improvement and better reimbursement.
• Complete coding for daily charts and maintain 96%+ accuracy across service lines.
• Document deficiency data and query physicians when needed for clarification.
• Ensure timely delivery of coded charts and proper escalation of workflow issues.

Skills

Medical coding knowledge

Analytical skills

High concentration

Communication with physicians

Independent work

MS Office proficiency

Education

CPC or CCS-P certification

ED/ICU/Hospitalist coding experience

Tools

EHR systems

Billing platforms

Microsoft Office

Job description

Medical Coding Specialist

Under general supervision, this position is responsible for the following activities: application of the appropriate CPT and ICD-10 codes to individual patient medical records; review of medical record documentation for the elements necessary to determine the appropriate code assignment; and for providing feedback to the physician regarding documentation improvement opportunities.

Assigned codes are used for physician reimbursement and to establish a statistical database for the company. This database is used throughout the organization for administrative planning and to meet regulatory reporting requirements.

Essential Duties and Responsibilities

Productivity /Efficiency

• Analyzes and evaluates medical record documentation to determine the appropriate CPT (E&M Level and procedure) codes and ICD-10 diagnosis codes that may be reported by the Client for billing purposes, according to current Brault policy, government regulations, and payer requirements.
• Completes coding functions for all charts assigned daily and distributes coded charts to the subsequent step in the workflow according to Brault P&P and departmental protocols.
• Reviews documentation for opportunities to improve physician documentation for services rendered, thus improving reimbursement.
• Completes documentation deficiency data collection forms for tracking/trending and reporting purposes.
• Completes incomplete documentation forms for use in querying the physician for additional information needed to code the account.
• Identifies accounts that are non-billable and or missing.
• Codes a minimum of 135-150 charts per day (18-20 per hour) with a 96% or greater accuracy.
• Delivers all work with one business days from the date the work became available to the coder.
• Communicates all variations to the established workflow and escalates all issues that prevent daily coding or month end close.
• Completes timecard and production records daily.
• Participates in team activities for quality assurance and peer review as assigned.
• Attends all departmental and company meetings.

Technical Skills

Correct Coding Assignments:

• Maintains current knowledge of CMS regulations, ICD-10-CM guidelines, CPT coding standards, and Brault coding policies. Applies coding assignment in accordance with federal, state, and compliance regulations.
• Assigns correct modifiers, as appropriate.
• Understands and applies rules regarding surgical packages.
• Applies codes for other medical services such as X-rays, EKGs, etc.
• Ensures coding and billing are based on medical record documentation according to the state and federal laws, regulations, Brault coding guidelines, and the OIG's coding compliance work plan.
• Ensures that all coded data is credible, reliable, and accurate reflections of the treatment provided to the patient.

Communication

Consistently communicates with others with respect, kindness, and understanding; is honest and clear; treats sensitive information confidentially; is perceived as positive and demonstrates quality services.

Quality

• Applies correct codes at the rate of 96% accuracy for all service lines trained in.
• Ensures patient's discharge status is accurate and complete.
• Escalates all problems with incomplete, missing, unbillable, clerical errors, late charts are appropriately and promptly.
• Ensures 100% on time coder close for each client.

Adherence to Policy and Procedure

• Adheres to all Company policies and procedures (i.e. Administrative and Human Resources), practices safe work habits, and engages in good business standards and practices.

Other Job Functions

• Provides coverage datasets other than the primary client, to ensure on time close in the case of vacation, sick leave, etc.
• Accepts and performs other related duties and responsibilities as required upon request of the manager.
• Participates in in-services and continuing education activities.

Requirements

Knowledge, Skills, & Abilities

• Demonstrates extensive knowledge of disease entities and disease process, medical terminology, anatomy, physiology, medication purposes, and administration, and the purpose and definitions of common medical procedures.
• Demonstrates analytical skills, and the ability to translate documentation in various parts of a medical record into specific codes.
• The ability to work a fast pace and maintain a high concentration level with accuracy.
• The ability to effectively and tactfully communicate the relationship between coding and documentation with physicians.
• Demonstrates high proficiency in maintaining the quality and quantity of coding standards.
• Ability to work independently with minimal supervision, to work under pressure, and to work under deadlines.
• Computer keyboarding skills, and experience with MS Office.

Education & Experience Requirements

• Requires completion of a defined training program resulting in a CPC or CCS-P by an accredited institution (AAPC, AHIMA).
• Background in ED, Urgent Care, ICU and/or hospitalist coding preferred.
• Credentialed coders must have a minimum of three years of experience in evaluation and management and CPT coding.
• Excellent understanding of ethical coding, reimbursement and documentation compliance.
• Experience with Electronic Health Record systems (EHR), coding/billing platforms and Microsoft Office Applications