Outpatient Coder II

Nuvance Health•Poughkeepsie, NY

63d•$24 - $46•Remote

About The Position

Nuvance Health is seeking an experienced Outpatient Coder II skilled in Evaluation and Management (E/M) leveling, critical care coding, and trauma surgery coding. The ideal candidate will accurately code and abstract outpatient medical records for reimbursement, compliance, and statistical reporting. Candidates with strong experience in trauma surgery, acute care, and E/M specialty coding will thrive in this role. Knowledge of ICD-10-CM, CPT-4, and modifier usage is essential.

Requirements

Certification: CPC, COC, CCS, or CCS-P
Training in medical terminology, ICD-10-CM diagnosis, CPT procedure, and E/M coding
Ability to interpret operative reports, medical orders, and clinical documentation
Minimum 2 years of acute care and outpatient coding experience in trauma surgery

Responsibilities

Accurately code all outpatient trauma and surgical encounters, including emergency department, trauma consults, and critical care cases.
Assign appropriate ICD-10-CM and CPT-4 codes following established coding and documentation guidelines.
Perform E/M leveling for trauma specialists, including critical care and complex surgical evaluations.
Query physicians and departments for clarification when documentation is incomplete, conflicting, or ambiguous.
Ensure compliance with all federal, state, and organizational coding regulations.
Maintain 95% or higher accuracy rate in diagnostic and procedural coding.
Participate in quality assurance and performance improvement activities.
Stay current with coding updates, regulatory changes, and best practices through continuing education.
Code encounters where patients present to the Emergency Department (ED) as trauma cases.
Assign appropriate codes for procedures and diagnoses such as gunshot wounds, motor vehicle accidents (MVAs), acute abdomen, and traumatic injuries.
Review operative reports for trauma-related procedures (e.g., exploratory laparotomy, fracture repair, wound closure, and general surgical interventions).
Collaborate with trauma surgeons and clinical documentation specialists to ensure precise representation of the patient encounter.