Certified Coder
About The Position
The Certified Coder reviews clinical documentation and applies the appropriate codes and modifiers for clinical services performed in office and/or hospital settings, including surgical and non-surgical procedures. The position ensures that documentation supports the services billed and complies with regulatory requirements, provider documentation guidelines, CPT documentation standards, and CMS coding guidelines. The role reviews records for professional services in clinic, inpatient, and/or outpatient settings; verifies diagnoses and other codes; and communicates with hospitals and physicians to obtain additional documentation when needed. It also supports timely charge posting, assists and trains staff, and contributes to projects within the scope of the role. The position is based in an office, with remote work optional based on productivity and accuracy standards.
Requirements
- High school diploma or GED required.
- Experience in professional and facility coding.
- One of the following AHIMA or AAPC certifications required: CPC, CCS, CCS-P, RHIT, or RHIA.
- Expert knowledge of CPT, HCPCS, E/M leveling, modifiers, and ICD-10-CM diagnostic coding.
- Proficient computer skills with MS Word, Excel, PowerPoint, Outlook, Teams, Microsoft Edge, and EncoderPro.
- Use Official Guidelines for Coding and Reporting, Coding Clinics, and CPT to ensure coding accuracy.
- Strong analytical and communication skills.
- Provide excellent internal and external customer service and adhere to Springfield Clinic's Code of Conduct and Ethics Standards.
- Maintain credentialing CEUs and follow Clinic operating procedures and policies.
Nice To Haves
- College degree in a health-related field.
- Two years of experience as a certified coder.
- Knowledge of Athena, Ingenious Med, and RCX.
Responsibilities
- Review and analyze medical-record documentation for professional services related to clinic, inpatient, and/or outpatient care.
- Verify and code diagnoses, evaluation and management services, procedures, and other codes needed for complete and accurate records.
- Code or review encounters to identify first-listed diagnoses, comorbidities, complications, and therapeutic and diagnostic procedures using ICD-10, CPT, HCPCS, and other required coding systems.
- Examine records for authorized signatures and patient identification, and ensure documentation adequately supports diagnoses and treatment and describes results.
- Communicate with hospitals and physicians to obtain additional documentation when needed to meet coding requirements.
- Ensure charges are posted in a timely manner as directed by the Manager.
- Assist other staff, including training fellow coders in areas of expertise.
- Assist the Director or Manager with projects related to the role's knowledge and responsibilities.
- Comply with Springfield Clinic incident-reporting policies and procedures.
- Adhere to required OSHA and Springfield Clinic training and accomplishment policies.
- Provide excellent customer service and follow Springfield Clinic's Code of Conduct and Ethics Standards.
- Attend conferences, in-services, and workshops as directed to support professional development and job knowledge.
- Maintain credentialing CEUs and follow Clinic operating procedures and policies.
- Perform other duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
