OUTPATIENT CODER (CERT)

McDonough District Hospital•Macomb, IL

About The Position

Codes and abstracts hospital outpatient medical records, including emergency department encounters, outpatient surgical services, observation services, rehabilitation services, infusion, and other hospital outpatient visits. Coding supports reimbursement, data reporting, research, and compliance with applicable coding guidelines and regulatory requirements. Assigns appropriate ICD-10-CM diagnosis codes, CPT procedure codes, and HCPCS codes based on provider documentation and applicable coding guidelines. Reviews medical records for completeness, accuracy, and appropriate code assignment; identifies documentation deficiencies and coding discrepancies; and coordinates follow-up or clarification when necessary. Applies established coding standards to support accurate billing, compliant reimbursement, data integrity, and revenue cycle performance.

Requirements

High school diploma or equivalent.
Current coding certification from AAPC or AHIMA; acceptable credentials may include CPC, COC, CCS, CCA, RHIT, RHIA, or another organization-approved credential appropriate to the position.
Minimum of 2–3 years of hospital outpatient coding experience.
Experience with electronic health records and computerized coding and encoding software.
Knowledge of ICD-10-CM, CPT, and HCPCS coding systems and applicable coding guidelines.
Knowledge of hospital outpatient coding requirements, including emergency department, outpatient surgery, and observation services.
Knowledge of medical terminology, anatomy, physiology, and common disease processes sufficient to interpret clinical documentation.
Ability to review records for complete, accurate, and consistent documentation and identify when clarification is needed.
Knowledge of coding accuracy standards, auditing practices, coding edits, modifiers, medical necessity requirements, payer rules, and regulatory requirements.
Ability to work independently and recognize when clarification, assistance, or escalation is necessary.
Strong analytical, critical-thinking, problem-solving, and attention-to-detail skills.
Ability to organize and prioritize work, adapt to changing guidelines and workflows, and meet accuracy and productivity expectations.
Ability to communicate professionally and maintain confidentiality of protected health information.

Nice To Haves

Previous medical billing, claims processing, or revenue cycle experience.

Responsibilities

Code and abstract hospital outpatient medical records, including emergency department, outpatient surgery, observation, rehabilitation, infusion, and other outpatient services.
Assign appropriate ICD-10-CM diagnosis, CPT procedure, and HCPCS codes based on provider documentation and applicable guidelines.
Review medical records for completeness, accuracy, and appropriate code assignment; identify documentation deficiencies and coding discrepancies.
Coordinate follow-up or clarification with physicians, other qualified healthcare providers, or designated personnel when needed.
Research coding questions using authoritative references, payer guidance, and organizational procedures.
Meet established coding accuracy standards, with a target of 95% or greater, and assigned productivity expectations.
Complete assigned accounts within established timelines while prioritizing competing work demands.
Participate in coding audits and educational activities, accept feedback, and apply opportunities for improvement.
Maintain confidentiality and safeguard protected health information.
Communicate professionally with physicians, hospital staff, and other departments to resolve coding and documentation issues.