Medical Records Coder IV, Complex

University of Rochester•Rochester, NY

7d•Remote

About The Position

The Medical Records Coder IV, Complex functions as an advanced coder, abstracting and performing in-depth analysis of medical documentation across multiple specialties. The role assigns appropriate procedural terminology and medical codes in accordance with applicable coding rules and policies, including ICD-10, CPT-4, HCPCS, and DRG. It also analyzes, enters, and manipulates database information and responds to or clarifies internal requests for medical information. The position reviews codes generated through electronic charge capture and assigns codes from medical record documentation according to recognized coding guidelines. It reviews and resolves coding denials, claim errors, and coding issues; abstracts data and checks coding accuracy; performs system edit checks; and communicates documentation improvement opportunities. The coder consults with internal customers and external vendors when documentation is inconsistent, incomplete, or requires clarification. Other duties may be assigned. This is a per-diem position with scheduled hours as needed. The listing identifies remote work in New York. The stated compensation range is $25.14–$35.24; the individual rate is determined by factors including market data, education, experience, qualifications, expertise, and internal equity.

Requirements

High school diploma or equivalent and 3 years of experience as a Medical Coder, or an equivalent combination of education and experience.
Knowledge of ICD-10-CM, CPT, and HCPCS.
Working knowledge of medical terminology and anatomy.

Nice To Haves

Associate’s degree in Health Information Technology or a health-related field.
Additional coding experience in the area of assignment.
AHIMA accreditation as a Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), or Certified Coding Specialist (CCS).
Certified Professional Coder (CPC) from AAPC or Certified Medical Coder (CMC) from Practice Management Institute.

Responsibilities

Use knowledge of coding systems and system logic to review codes created by electronic charge capture and/or assign ICD-10-CM, E/M, CPT, HCPCS, and modifier codes from medical record documentation in accordance with recognized coding guidelines.
Review and resolve coding denials.
Resolve claims with errors related to improper coding and provide feedback for correction and follow-up.
Abstract data and review codes for accuracy.
Perform system edit checks and correct errors as needed.
Respond to coding information requests from various sources.
Communicate documentation improvement opportunities and coding issues to providers, departments, and/or designated leaders for follow-up and resolution.
Consult with internal customers and external vendors to obtain specificity or clarification when documentation appears inconsistent or incomplete.
Analyze, enter, and manipulate database information.
Respond to or clarify internal requests for medical information.
Perform other duties as assigned.