Inpatient Medical Coder (Remote)

CABAN RESOURCES, LLC•, FL

21h•Remote

About The Position

The Inpatient Medical Coder assigns codes from medical record documentation for professional and facility components of ambulatory emergency room encounters. Coding may also include ambulatory or outpatient encounters as directed. The role reviews documentation, resolves or escalates issues that could affect coding accuracy or quality patient care, and supports coding compliance through appropriate research and clarification. The coder also educates providers and clinical staff, answers coding questions, collaborates with auditors, trainers, and CDI specialists, and meets the position’s productivity and accuracy standards. Under coding supervisors’ direction, the position uses computer systems to access patient records remotely and assign codes.

Requirements

Hold one of the following recognized professional coding certifications: Certified Coding Specialist (CCS), Certified Professional Coder (CPC), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA).

Nice To Haves

Certified Evaluation and Management Coder (CEMC) certification.
National Alliance of Medical Auditing Specialists’ Certified Evaluation and Management Auditor (CEMA) certification.

Responsibilities

Assign E/M, ICD-CM diagnosis, ICD-10-PCS, CPT, HCPCS, modifier, and quantity codes based on medical record documentation for professional and facility components of ambulatory emergency room encounters; code ambulatory or outpatient encounters as directed.
Review encounter and record documentation to identify and resolve inconsistencies, ambiguities, or discrepancies that could cause inaccurate coding or affect quality patient care.
Identify issues with legibility or abbreviations and bring them to the provider’s attention.
Educate and provide feedback to providers and clinical staff to resolve documentation issues and support coding compliance.
Assign accurate codes to encounters based on provider responses to coding queries.
Serve as a coding resource for medical staff, respond to questions, and provide examples and documentation references to clarify coding.
Collaborate with and support medical coding auditors, trainers, and CDI specialists in educating and providing feedback to providers and staff.
Research or interpret existing guidance ethically and appropriately, seeking clarification through appropriate channels when needed.
Use computer systems to remotely access patient records and assign encounter codes upon coding supervisors’ direction.
Meet and maintain the position’s coding productivity and accuracy standards.