Coder Inpatient

Omega•Boca Raton, FL

3d•Remote

About The Position

This role is responsible for abstracting, coding, sequencing, and interpreting clinical information from various medical records including inpatient, outpatient, emergency department, pro fee, and clinical records. The coder will assign principal and secondary diagnoses and procedure codes with accurate sequencing, utilizing technical coding principles and DRG/APC reimbursement expertise. They will abstract and code pertinent medical data into multiple software programs and encoders, following official coding guidelines to review and analyze health records. The position requires maintaining compliance with external regulatory and accreditation requirements, as well as State and Federal regulations. The coder will extract pertinent data, determine appropriate coding for reports and billing documents, and identify codes for medical services and physician-performed procedures, entering them into various computer systems. Productivity tracking and maintenance of a 95% quality rating are essential. Duties must be performed in compliance with company policies, including HIPAA and compliance regulations.

Requirements

Ability to prioritize and multi-task in a fast-paced, changing environment.
Demonstrate ability to work in all work types and specialties.
Demonstrate ability to self-motivate, set goals, and meet deadlines.
Demonstrate leadership, mentoring, and interpersonal skills.
Demonstrate excellent presentation, verbal and written communication skills.
Ability to develop and maintain relationships with key business partners by building personal credibility and trust.
Maintain courteous and professional working relationships with employees at all levels of the organization.
Demonstrate excellent analytical, critical thinking and problem solving skills.
Skill in operating a personal computer and utilizing a variety of software applications.
Knowledge of coding convention and rules established by the AHIMA, American Medical Association (AMA), the American Hospital Association (AHA) and the Center for Medicare and Medicaid (CMS), for assignment of diagnostic and surgical procedural codes.
Knowledge of JCAHO, coding compliance and HIPAA HITECH standards affecting medical records and the impact on reimbursement and accreditation.
Successful completion of an AAPC or AHIMA-approved Coding Certificate Program.
A minimum of two to four years of current production coding experience in both acute care and profee.
Must have the following certificates and/or licenses: CPC, COC, CIC, RHIA, RHIT, CCS, and/or CCS-P.

Responsibilities

Abstracting, coding, sequencing, and interpreting clinical information from inpatient, outpatient, emergency department, pro fee, and clinical medical records.
Assigning correct principal diagnoses, secondary diagnoses, principal procedure, and secondary procedure codes with attention to accurate sequencing.
Utilizing technical coding principals and DRG/APC reimbursement expertise to assign appropriate codes.
Abstracting and coding pertinent medical data into multiple software programs and/or encoders.
Following official coding guidelines to review and analyze health records.
Maintaining compliance with both external regulatory and accreditation requirements, and with State and Federal regulations.
Extracting pertinent data from the patient’s health record, and determining appropriate coding for reports and billing documents.
Identifying codes for reporting medical services, procedures performed by physicians.
Entering codes into various computer systems dependent upon the various clients.
Tracking and documenting productivity in specified systems, maintaining productivity levels as defined by the client.
Maintaining a 95% quality rating.
Performing duties in compliance with Company’s policies and procedures, including but not limited to those related to HIPAA and compliance.