Coder II - Outpatient

Avera•Sioux Falls, SD

1d•Onsite

About The Position

The Coder II is responsible for timely and accurate assignment of diagnostic and procedural codes for a variety of outpatient charts across multiple Avera Health facilities. The role also involves accurate abstracting, reporting, and editing. The Coder II works independently to meet quality and production goals, with occasional guidance from other professional staff. The position reviews clinical documentation and assigns the appropriate ICD-10-CM, CPT, and HCPCS diagnosis and procedure codes. It focuses on APC/EAPC and medical coding for outpatient services, including emergency room, ancillary, imaging, laboratory, physical therapy, occupational therapy, speech pathology, and dialysis. The Coder II may serve as a subject matter expert, query physicians and clinical documentation staff to capture the full clinical record, and assist with or lead communication among health information management, billing, and providers. The role maintains personal quality and production statistics according to service-line standards.

Requirements

Obtain one of the following within 180 days: Certified Coding Associate (CCA), Certified Coding Specialist–Physician-based (CCS-P), Certified Coding Specialist (CCS), Certified Outpatient Coder (COC), Certified Professional Coder (CPC), Registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT).
Ability to work the specified hours.
Visual acuity adequate to perform position duties.
Ability to communicate effectively, hear, understand, and distinguish speech and other sounds.
Ability to perform the essential job functions satisfactorily, with reasonable accommodations where applicable.
Commitment to Avera’s mission, vision, core values, and social principles; promote compassion, hospitality, and stewardship.
Uphold Avera’s CARE standards: Communication, Attitude, Responsiveness, and Engagement.
Maintain confidentiality and work effectively in a team environment.
Comply with applicable safety principles, laws, regulations, and standards, including CMS, The Joint Commission, DHHS, and OSHA where applicable.

Nice To Haves

Associate degree in Health Information Administration or Health Information Technology.
1–3 years of coding experience.

Responsibilities

Review clinical documentation and assign appropriate ICD-10-CM, CPT, and HCPCS diagnosis and procedure codes for assigned outpatient charts across Avera facilities.
Determine appropriate APC/EAPC and/or medical coding for outpatient services, including ER, ancillary, imaging, lab, PT, OT, speech pathology, and dialysis.
Keep coding knowledge current through research and educational opportunities.
Occasionally serve as a subject matter expert for other health professionals within Avera.
Query physicians and clinical documentation staff to ensure full capture of the clinical record.
Assist with or lead communication between health information management, billing, and providers as needed.
Maintain personal quality and production statistics in accordance with Coder II service-line standards.