Coder III : Medical Coding
About The Position
The Coder III position involves reviewing clinical documentation and diagnostic results to apply appropriate ICD-10-CM and ICD-10-PCS codes for billing, reporting, research, and regulatory compliance. The role adheres to ethical coding standards and official coding guidelines. Responsibilities include verifying correct ICD-10-CM codes and physician abstraction, staying updated on coding guideline changes, and participating in quality review meetings. For hospital-based medical coding, the role also resolves billing errors, assists with workflow improvements, and meets productivity standards of 95% accuracy. The Coder III assigns codes for inpatient surgeries, determines principal diagnoses, co-morbidities, complications, secondary conditions, and surgical procedures. They abstract required information, assign correct MS-DRG and APR-DRG, Present on Admission (POA) indicators, and identify Hospital Acquired Conditions (HAC). The position also involves querying physicians when documentation is unclear or conflicting.
Requirements
- High school diploma or equivalent required.
- Completion of a certified coding program or graduate of a CAHIM accredited HIT program required.
- Five years of progressive inpatient coding experience in an acute care facility.
- Five or more (5+) years coding experience mastering assigning diagnostic and procedure codes to patient medical records.
- Extensive outpatient coding experience in multiple areas of specialty.
- Certified Coding Specialist (CCS)
Responsibilities
- Reviews clinical documentation and diagnostic results and applies appropriate ICD-10-CM and ICD-10-PCS to support diagnoses, procedures, and treatment results.
- Abides by the standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to all official coding guidelines.
- Verifies that all ICD-10-CM codes are correctly captured.
- Verify that physician is correctly abstracted.
- Keeps abreast of coding guideline changes by self-study, assigned education, coding meeting attendance or related in-services.
- Participates in internal and external quality review meetings.
- Performs other duties as assigned.
- Resolves billing related errors and assists with workflow changes and process improvement projects.
- Meets ongoing productivity and quality standard of 95% accuracy rate or better.
- Assigns codes for diagnoses, treatment, and procedures for inpatient surgeries.
- Determines the correct principal diagnosis, co-morbidities, complications, secondary conditions, and surgical procedures.
- Abstracts correctly all required information from record including the correct discharge disposition and OSHPD required information.
- Assigns correct MS-DRG and APR-DRG and correct Present on Admission (POA) indicators and identifies (HAC) Hospital Acquired Conditions.
- Queries physicians per established policy and procedure when documentation is not clear or conflicting.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
