About The Position

The Outpatient Medical Coder is responsible for reviewing clinical documentation and diagnostic results to accurately assign ICD-10-CM, CPT-4, and modifier codes. This role ensures compliance with regulatory standards while supporting billing, reporting, and research functions. The coder plays a key role in maintaining coding accuracy, integrity, and overall data quality.

Requirements

  • High School Diploma or GED
  • One of the following certifications: Certified Coding Specialist (CCS) Certified Professional Coder (CPC) Registered Health Information Technician (RHIT) Certified Medical Coder (CMC) Certified Coding Associate (CCA)
  • Minimum 2 years of outpatient E/M coding experience
  • Strong understanding of ICD-10-CM and CPT coding guidelines
  • Knowledge of compliance standards and regulatory requirements

Nice To Haves

  • Associate Degree in a healthcare-related field
  • Experience in outpatient Neurosurgery or Neurology coding
  • At least 6 months of HCC coding experience
  • Experience with EPIC EHR systems
  • Ability to code physician services in Neurology

Responsibilities

  • Assign accurate diagnosis and procedure codes for outpatient encounters using ICD-10-CM, CPT-4, and applicable modifiers
  • Review and analyze clinical documentation to ensure completeness and accuracy
  • Extract and interpret relevant clinical data for coding purposes
  • Apply official coding guidelines and organizational compliance standards
  • Utilize knowledge of APC reimbursement methodologies and coding best practices
  • Communicate effectively with providers, clinical staff, and leadership
  • Query providers for clarification when documentation is incomplete or unclear
  • Ensure adherence to ethical coding standards
  • Maintain productivity and quality benchmarks
  • Support patient safety and organizational compliance policies
  • Contribute to team development through mentoring and knowledge sharing
  • Participate in ongoing education and professional development
  • Perform additional duties as assigned

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What This Job Offers

Career Level

Mid Level

Education Level

High school or GED

Number of Employees

1-10 employees

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