Health Information Coder (Remote Candidates Considered)

Cape Cod Healthcare • Hyannis, MA

76d

About The Position

The position involves analyzing, sequencing, and validating assigned codes based on medical record documentation using automated encoders and coding compliance resources. The coder must demonstrate a complete understanding of coding rules, anatomy, physiology, and medical terminology to appropriately code patient information. Responsibilities include reviewing medical record documentation to assign diagnoses, procedures, level codes, and modifiers, ensuring compliance with coding regulations and reimbursement requirements. The coder will also abstract and enter relevant patient information into medical record systems, assess documentation adequacy, and query healthcare providers for clarification when necessary. Maintaining a high accuracy rate and achieving productivity standards is essential, along with assisting in the orientation of new coding personnel and pursuing ongoing professional development.

Requirements

• Ability to read, write and communicate in English.
• Current CCS (AHIMA Certified Coding Specialist).
• 6 months of PC windows experience.
• 2 years CCH outpatient coding experience as an Outpatient Health Information Coding and Reimbursement Specialist.
• 6 months coding experience in one of the following outpatient specialties: Pain Management, Surgical Day Care, Oncology, Radiation or Observation.

Nice To Haves

• 6 months of inpatient coding experience.
• Successful passage of Medical Record Department Inpatient Coding exam with a grade of 80% or better.

Responsibilities

• Analyzes, sequences and validates assigned codes based on medical record documentation using the automated encoder.
• Demonstrates complete understanding of coding rules, anatomy, physiology, and medical terminology to appropriately code patient information.
• Reviews all medical record documentation to determine and assign diagnoses, procedures, level codes and modifiers.
• Selects the appropriate reimbursement grouper based on financial class for the particular account.
• Ensures that coding compliance, regulatory and reimbursement requirements are met.
• Abstracts and enters diagnosis, procedures and level codes with demographic, clinical and related patient information into the Medical Record Abstracting and/or Billing/Accounts Receivable systems.
• Assesses adequacy of documentation and queries physicians and other healthcare providers for additional medical record documentation.
• Reconciles, identifies and retrieves medical records to be coded, grouped and abstracted.
• Maintains a 95% ongoing accuracy rate based on performance monitors and audits.
• Achieves weekly coding output within minimal productivity standards.
• Maintains accurate productivity logs and provides this information to the Coding Manager.
• Assists in the orientation and development of new coding personnel.
• Assumes professional responsibility for development of skills and ongoing education to maintain certification.
• Remains abreast of developments in health information management.
• Continuously monitors medical record documentation and department workflow to identify problems and potential solutions.
• Performs all duties in accordance with the Hospital's Customer Service standards.
• Performs other work-related duties as assigned or requested.

What This Job Offers

• Number of Employees: 5,001-10,000 employees