Specialty Coder - Medical Records

Prime Healthcare • Lewiston, ME

1d • Onsite

About The Position

The Specialty Coder reviews and analyzes documentation present in the medical record for both inpatient and outpatient visits to ensure accuracy of diagnosis and procedure codes assigned by the Coders or Clinical Documentation Specialists (CDS) or Computer Assisted Coding (CAC) software. The Coder Auditor finalizes the coding and abstracting of the medical record upon ensuring the assignment of International Classifications of Diseases, Ninth Revision (ICD-9-CM) or Tenth revision (ICD-10/PCS), Current Procedural Terminology (CPT), and Health Care Procedure Coding System (HCPCS), are accurate and supported by the clinical documentation of the respective medial record. Holding a senior coding position, assumes primary responsibility for DRG validation/accuracy, primary role in assisting CDS and medical staff members with improving quality of clinical documentation. Participates in chart review projects as assigned and other duties as needed.

Requirements

• High school graduate or equivalent.
• CCS required.
• Basic computer experience required.
• Use of an encoder software product for code assignment in an acute care setting required.
• Computer data entry with 10-key preferred, with accurate typing speed of 35 wpm preferred.
• Excellent written and verbal communication skills.
• Excellent critical thinking skills.
• Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, coding staff and hospital management staff.
• Ability to work independently in a time-oriented environment.
• Computer literacy and familiarity with the operation of basic office equipment.

Nice To Haves

• 1+ year of clinical experience in acute care setting preferred.
• Must meet the performance standards set forth by the Hospital/ Department at Coder Auditor position for at least 6 months.
• Minimum of two years’ experience with ICD-9 and CPT coding in an acute care setting preferred.

Responsibilities

• Reviews and analyzes documentation present in the medical record for both inpatient and outpatient visits to ensure accuracy of diagnosis and procedure codes assigned by the Coders or Clinical Documentation Specialists (CDS) or Computer Assisted Coding (CAC) software.
• Finalizes the coding and abstracting of the medical record upon ensuring the assignment of International Classifications of Diseases, Ninth Revision (ICD-9-CM) or Tenth revision (ICD-10/PCS), Current Procedural Terminology (CPT), and Health Care Procedure Coding System (HCPCS), are accurate and supported by the clinical documentation of the respective medial record.
• Assumes primary responsibility for DRG validation/accuracy.
• Plays a primary role in assisting CDS and medical staff members with improving quality of clinical documentation.
• Participates in chart review projects as assigned.
• Performs other duties as needed.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: High school or GED