Coder Inpatient

Omega Healthcare Management Services•Boca Raton, FL

3d•Remote

About The Position

The Coder Inpatient abstracts, codes, sequences, and interprets clinical information from inpatient, outpatient, emergency department, professional-fee, and clinical medical records. The role assigns accurate principal and secondary diagnoses and procedures, applies coding principles and DRG/APC reimbursement expertise, and enters pertinent medical data into software programs, encoders, computer systems, and client-specific systems. The coder follows official coding guidelines and maintains compliance with regulatory, accreditation, State, and Federal requirements, including HIPAA and company policies. This is a full-time position performed in a remote home office. Work is generally Monday through Friday, 8:00 a.m. to 5:00 p.m., with occasional long hours and weekend work. Minimal travel is required, up to 5%. The position requires maintaining client-defined productivity levels and a 95% quality rating. Systems mentioned include Meditech, Cerner, and Solventum; the employee must be willing to learn other systems as needed.

Requirements

Successful completion of an AAPC- or AHIMA-approved Coding Certificate Program (the qualifications section also specifies an AHIMA-approved program).
Two to four years of current production coding experience in both acute care and professional-fee coding; the qualifications section also specifies at least three years of current production coding experience in acute care.
At least one of the following certificates or licenses: CPC, COC, CIC, RHIA, RHIT, CCS, and/or CCS-P. The qualifications section specifically lists RHIA, RHIT, and CCS.
Knowledge of coding conventions and rules established by AHIMA, AMA, AHA, and CMS for diagnostic and surgical procedural code assignment.
Knowledge of JCAHO, coding compliance, and HIPAA HITECH standards affecting medical records and reimbursement and accreditation.
Ability to prioritize and multitask in a fast-paced, changing environment and work across work types and specialties.
Ability to self-motivate, set goals, and meet deadlines.
Leadership, mentoring, interpersonal, presentation, verbal communication, and written communication skills.
Ability to build and maintain relationships with business partners through credibility and trust, and maintain professional working relationships with employees at all organizational levels.
Strong analytical, critical-thinking, and problem-solving skills.
Skill in operating a personal computer and using a variety of software applications.
Ability to use Meditech, Cerner, and Solventum, and willingness to learn other systems as needed.
Ability to meet the position’s occasional physical demands, including occasionally lifting or moving up to 25 pounds.

Responsibilities

Abstract, code, sequence, and interpret clinical information from inpatient, outpatient, emergency department, professional-fee, and clinical medical records.
Assign accurate principal and secondary diagnoses and principal and secondary procedure codes, with attention to sequencing.
Apply coding principles and DRG/APC reimbursement expertise to assign appropriate codes.
Abstract and code pertinent medical data into software programs and encoders.
Follow official coding guidelines when reviewing and analyzing health records.
Maintain compliance with external regulatory and accreditation requirements, State and Federal regulations, HIPAA, and company policies and procedures.
Extract pertinent data from patient health records and determine appropriate coding for reports and billing documents.
Identify codes for reporting medical services and procedures performed by physicians.
Enter codes into computer systems as required by different clients.
Track and document productivity in specified systems and maintain client-defined productivity levels.
Maintain a 95% quality rating.
Perform other duties as assigned; duties and responsibilities may change.
Travel up to 5% as required.