Medical Coder III (Inpatient Coder)

Caban Resources•Portsmouth, VA

3h•Hybrid

About The Position

This role provides single path medical coding services, combining facility and professional coding, allowing one coder to manage both for the same patient using a single platform. The position involves technically complex professional services coding for medical conditions across various specialties. This includes coding complicated cases such as burn injuries, combat-related injuries, orthopedic surgery, cardiothoracic surgery, interventional radiology, new diseases, and experimental treatments or therapies.

Requirements

Post-high school education through a university or technical school program resulting in completion of ONE of the following: An Associate's degree or higher in Health Information Management, Healthcare Administration, or a biological science; OR A university certificate in medical coding; OR At least 30 semester hours' university/college credit that includes relevant coursework such as anatomy/physiology, medical terminology, health information management, and/or pharmacology; OR Successful completion of an American Academy of Professional Coders (AAPC) or American Health Information Management Association (AHIMA) coding preparation course for professional services or facility coding that includes medical terminology, anatomy and physiology, health information management concepts, and pharmacology; OR Successful completion of a training course beyond apprentice level for medical technicians, hospital corpsmen, medical service specialists, or hospital training, obtained in a training program given by the Armed Forces or the U.S. Maritime Service under close medical and professional supervision.
General medical ethics.
Telephone etiquette.
Excellent communication and customer service skills.
ONE of the following recognized professional coding certifications: Certified Professional Coder (CPC), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Specialist – Physician (CCS-P).
ONE of the following recognized institutional coding certifications: Certified Inpatient Coder (CIC), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Specialist (CCS).

Responsibilities

Accurately assign Evaluation and Management (E&M) codes, International Classification of Diseases, Clinical Modification (ICD-CM) diagnoses, ICD-10 Procedure Coding System (ICD-10-PCS), Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), modifiers, and quantities derived from medical record documentation for professional and institutional components of inpatient facility discharges, inpatient professional services (attending, consultations, concurrent services), inpatient surgical and anesthesia procedures, and inpatient External Resource Sharing Agreement (ERSA) encounters.
May also code ambulatory or outpatient encounters as directed.
Review encounter and/or record documentation to identify and resolve inconsistencies, ambiguities, or discrepancies that may impact coding accuracy, medico-legal outcomes, or patient care quality.
Educate and provide feedback to providers and clinical staff to resolve documentation issues and support coding compliance.
Assign accurate codes based on provider responses to coding queries.
Serve as a reference for medical staff with questions, issues, or concerns related to coding.
Respond to provider questions, providing examples of appropriate coding and documentation references.
Collaborate with and support medical coding auditors, trainers, and compliance specialists in providing education and feedback.
Support DHA coding compliance by performing due diligence in ethically and appropriately researching and/or interpreting existing guidance, including seeking clarification through appropriate channels.
Utilize MHS computer systems to remotely access patient records and assign codes for patient encounters in support of other MTFs, upon DHA-MCPB direction.
Achieve and maintain DHA coding productivity and accuracy standards.