Coder, Certified

Shenandoah Medical Center•Shenandoah, IA

About The Position

The Certified Coder reviews clinical documentation and accurately codes and sequences diagnoses and procedures according to applicable coding guidelines. The role abstracts clinical information, assigns charge master codes and modifiers for billing, and uses information systems to select patient accounts and enter billable charges. The coder participates in audits, resolves documentation and billing issues with staff, providers, and departments, and collaborates with healthcare providers, compliance, and coding teams to identify documentation changes that may improve reimbursement. The position maintains current knowledge of coding standards, regulations, and changes to ICD-10-CM/PCS, CPT-4, and HCPCS. It develops and implements continuing education objectives to maintain relevant coding certifications and professional standards. The coder also organizes documentation data to identify trends and provides feedback and education to staff and healthcare providers to improve capture of billable items. The role follows organizational policies, procedures, and regulatory requirements; participates in safety and quality activities; and performs other duties as assigned.

Requirements

Maintain a current coding certification such as CPC, COC, CCS, or CCS-P and meet its continuing education requirements.
Maintain current knowledge of national NCCI coding standards and applicable JCAHO/CMS requirements.
Maintain current knowledge of ICD-10-CM/PCS, CPT-4, and HCPCS changes.
Demonstrate organizational skills, self-motivation, and flexibility.

Responsibilities

Accurately code and sequence diagnoses and procedures according to coding guidelines and abstract clinical information for reimbursement.
Review documentation to determine diagnoses and procedures performed.
Assign charge master codes and modifiers for appropriate billing and sequencing.
Use information systems to select the correct patient account and enter billable charges.
Participate in audits to identify lost charges and assess billing and coding accuracy.
Contact staff and providers regarding missing or inaccurate documentation and work with departments to resolve billing issues.
Collaborate with healthcare providers, compliance, and coding teams to identify documentation changes that may improve reimbursement.
Develop educational objectives and pursue continuing education to maintain coding knowledge, certification requirements, and professional standards.
Maintain current knowledge of national NCCI coding standards, JCAHO/CMS requirements, and applicable coding and billing criteria.
Maintain current knowledge of changes in ICD-10-CM/PCS, CPT-4, and HCPCS, and provide feedback and education about codes that have changed or are no longer appropriate for billable items.
Organize data to identify documentation trends and provide feedback to staff and healthcare providers to improve capture of billable items.
Comply with departmental and organizational policies, procedures, and regulatory requirements, including OSHA, CMS, and Joint Commission requirements.
Participate in corporate and departmental safety and quality activities.
Perform other duties as assigned.