Certified Coder

Springfield Clinic • Springfield, MO

7d

About The Position

The Certified Coder reviews clinical documentation and assigns 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 billed services and complies with regulatory requirements, provider documentation guidelines, CPT documentation, and CMS coding guidelines.

The coder reviews records for professional services across clinic, inpatient, and/or outpatient settings; verifies diagnoses, evaluation and management services, procedures, and other codes; and helps ensure records are complete and accurate. The role may include communicating with hospitals and physicians to obtain additional documentation, posting charges promptly, assisting and training other staff, and supporting projects within the role’s scope. The position reports to the Coding Unit Manager.

Work is in-office, with remote work optional based on productivity and accuracy standards. The position carries a HIPAA1 PHI/privacy level.

Requirements

• High school graduate or GED required.
• Must hold one of the following AHIMA or AAPC certifications: CPC, CCS, CCS-P, RHIT, or RHIA.
• Expert knowledge of CPT, HCPCS, evaluation and management leveling, modifiers, and ICD-10-CM diagnostic coding.
• Proficient computer skills using 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 preferred.
• Coding experience in professional and facility coding.
• Two years of experience as a certified coder preferred.
• Knowledge of Athena, Ingenious Med, and RCX preferred.

Responsibilities

• Review and analyze medical-record documentation for professional services related to clinic, inpatient, and/or outpatient services.
• Verify and code diagnoses, evaluation and management services, procedures, and other codes required 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 classification systems.
• Examine records for authorized signatures and patient identification, and ensure documentation sufficiently supports diagnoses and treatment and adequately describes results.
• Communicate with hospitals and physicians to obtain additional documentation when needed to complete coding requirements.
• Ensure charges are posted in a timely fashion as directed by the Manager.
• Assist other staff as necessary, including training fellow coders in areas of specialty expertise.
• Assist the Director or Manager with projects related to the position’s knowledge and responsibilities.
• Comply with Springfield Clinic incident-reporting policies and procedures.
• Adhere to OSHA requirements and Springfield Clinic training and accomplishment requirements as applicable under policy.
• Provide excellent customer service and adhere to Springfield Clinic’s Code of Conduct and Ethics Standards.
• Attend conferences, in-services, and workshops as directed to further professional development and job knowledge.
• Maintain credentialing CEUs and follow Clinic operating procedures and policies.
• Perform other job duties as assigned.

What This Job Offers

• Job Type: Full-time
• Education Level: High school or GED