Outpatient Medical Coder (Remote)

CABAN RESOURCES, LLC•, FL

1d•Remote

About The Position

This remote position involves accurately assigning Evaluation and Management (E&M) codes, ICD-CM diagnoses, ICD-10-PCS, CPT, HCPCS, modifiers, and quantities based on medical record documentation for the professional and facility components of ambulatory emergency room encounters. The role may also include coding for other ambulatory or outpatient encounters as directed. Key responsibilities include reviewing documentation to resolve inconsistencies, identifying and addressing issues with legibility or abbreviations, and educating providers and clinical staff on documentation improvements to ensure coding compliance. The coder will also respond to provider queries, act as a reference for coding-related questions, and collaborate with other coding professionals. The position requires utilizing computer systems to remotely access patient records and assign codes, while consistently meeting productivity and accuracy standards.

Requirements

Certification: ONE of the following recognized professional coding certifications: Certified Coding Specialist (CCS), Certified Professional Coder (CPC), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Specialist – Physician (CCS-P)
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 the professional and facility components of ambulatory emergency room.
Reviews encounter and/or record documentation to identify and resolve inconsistencies, ambiguities, or discrepancies that may cause inaccurate coding, and impacts to quality patient care.
Identifies any problems with legibility, abbreviations, etc., and brings to the provider's attention.
Educates and provides feedback to providers and clinical staff to resolve documentation issues to support coding compliance.
Assigns accurate codes to encounters based upon provider responses to coding queries.
Acts as a source of reference to medical staff having questions, issues, or concerns related to coding.
Responds to provider questions and provides examples of appropriate coding and documentation reference(s) to provide clarity and understanding.
Collaborates with and supports medical coding auditors, trainers, and CDI specialists in providing education and feedback to providers and staff.
Supports coding compliance by ethically and appropriately researching and/or interpreting existing guidance, including seeking clarification through appropriate channels.
Upon coding supervisors' direction, utilizes computer systems to remotely access patient records and assign codes for patient encounters.
Achieve and maintain coding productivity and accuracy standards for the position.

Nice To Haves

Certified Evaluation and Management Coder (CEMC), or National Alliance of Medical Auditing Specialists' (NAMAS) Certified Evaluation and Management Auditor (CEMA) certifications are a plus.

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 the professional and facility components of ambulatory emergency room.
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 cause inaccurate coding, and impacts to quality patient care.
Identify any problems with legibility, abbreviations, etc., and bring to the provider's attention.
Educate and provide feedback to providers and clinical staff to resolve documentation issues to support coding compliance.
Assign accurate codes to encounters based upon provider responses to coding queries.
Act as a source of reference to medical staff having questions, issues, or concerns related to coding.
Respond to provider questions and provide examples of appropriate coding and documentation reference(s) to provide clarity and understanding.
Collaborate with and support medical coding auditors, trainers, and CDI specialists in providing education and feedback to providers and staff.
Support coding compliance by ethically and appropriately researching and/or interpreting existing guidance, including seeking clarification through appropriate channels.
Upon coding supervisors' direction, utilize computer systems to remotely access patient records and assign codes for patient encounters.
Achieve and maintain coding productivity and accuracy standards for the position.