Health Information Management Sr Coder

CommonSpirit Health•Phoenix, AZ

About The Position

The Senior Coder accurately translates patients’ medical records into standardized codes for diagnoses and treatments, helping ensure services are documented correctly and insurance claims are processed efficiently. The role applies expert coding knowledge while following legal, regulatory, organizational, payer, and ethical standards. The position codes and abstracts assigned outpatient encounters using designated coding applications and systems. It reviews documentation for completeness and accuracy, coordinates physician queries when information is conflicting or incomplete, and works with providers and other departments to resolve documentation and charge discrepancies. The Senior Coder manages assigned work queues to meet productivity, turnaround-time, quality, and accuracy standards while maintaining strict confidentiality. The role also contributes to professional development and departmental improvement. Duties may include helping onboard and mentor new hires, contributing to audits and reports, sharing guidance on complex cases under leadership direction, and suggesting improvements to coding workflows, policies, and documentation initiatives. The position has no formal supervisory responsibility.

Requirements

High school graduate.
Completion of a CAHIIM-approved, AHIMA- or AAPC-accredited coding education program.
Three years of coding experience in inpatient, outpatient, professional fee, and/or outpatient physician clinic settings.
Experience using ICD-10-CM, CPT, HCPCS, and/or ICD-10-PCS coding.
Electronic medical record (EMR) and encoder experience.
One or more of the following credentials: Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Coding Specialist–Physician Based (CCS-P), Certified Professional Coder Hospital (CPC-H), Registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT).

Nice To Haves

Remote work experience.

Responsibilities

Assign and sequence ICD-10-CM, CPT, and HCPCS codes for outpatient medical records and encounters, substantiating coding decisions with medical record documentation and following official guidelines, payer requirements, and coding ethics standards.
Analyze APCs and modifier assignments and accurately code and abstract assigned encounters using designated coding applications and systems.
Identify conflicting, ambiguous, or incomplete documentation and initiate appropriate physician queries.
Collaborate with providers and other departments to improve clinical documentation and resolve charge discrepancies.
Prioritize and code assigned encounters within department productivity and turnaround-time requirements while meeting quality and accuracy standards.
Comply with applicable laws, rules, regulations, and organizational policies, including reporting suspected violations.
Maintain confidentiality of patients, medical records, the department, and employees.
Fulfill continuing education requirements and maintain professional credentials.
Contribute to a positive team environment and communicate effectively with colleagues and leadership.
May assist with new-hire onboarding, provide mentorship, and contribute to audits and reports.
Suggest improvements to coding workflows, efficiency, and documentation initiatives based on coding experience.
Provide feedback on proposed coding policies and procedures, identifying potential effects on coding accuracy or workflow.
Share expertise with less experienced coders on challenging cases under leadership direction and without formal supervisory responsibility.
Participate in departmental meetings and perform other duties as assigned.