In-patient Medical Coder

TEKsystems•Raleigh, NC

3d•$35 - $45•Remote

About The Position

Core Responsibilities Code & Abstract: Assign ICD-10-CM (diagnoses) and CPT (procedures) codes from physician documentation and medical records. Documentation Review: Evaluate records for completeness, accuracy, and compliance with coding guidelines and payer policies. Billing & Revenue Cycle: Resolve billing edits, manage charge capture, prevent denials, and ensure proper service capture for accurate reimbursement. Physician Collaboration: Educate physicians on documentation standards and work with Clinical Documentation Improvement (CDI) specialists. Data & Reporting: Ensure accurate data for DRGs, quality outcomes, internal/external reporting, and regulatory compliance. Auditing & Training: Conduct internal audits, defend coding decisions, and provide training for Coder I/II roles.

Requirements

CPC, CCS, RHIA, RHIT, or similar are required.
Varies by role (e.g., 2+ years for Coder II, 5+ years for Coder III in acute care).
Strong knowledge of ICD-10, CPT, coding conventions, anatomy/physiology, and revenue cycle processes.
Often a high-accuracy benchmark (e.g., 95%) for quality reviews.

Responsibilities

Assign ICD-10-CM (diagnoses) and CPT (procedures) codes from physician documentation and medical records.
Evaluate records for completeness, accuracy, and compliance with coding guidelines and payer policies.
Resolve billing edits, manage charge capture, prevent denials, and ensure proper service capture for accurate reimbursement.
Educate physicians on documentation standards and work with Clinical Documentation Improvement (CDI) specialists.
Ensure accurate data for DRGs, quality outcomes, internal/external reporting, and regulatory compliance.
Conduct internal audits, defend coding decisions, and provide training for Coder I/II roles.