This position requires candidates to reside in either Washington or Oregon.
Essential Responsibilities
Conduct proficient medical record reviews and translate clinical information into coded data.
Assign accurate codes for diagnoses, procedures, and services rendered, ensuring compliance with coding guidelines.
Utilize Code Base Charge Trigger (CBCT) and OPTUM 360 EncoderPRO software for professional surgical services.
Access patient encounter information through electronic patient data and EpicCare clinical systems.
Abstract and enter clinical data elements according to organizational requirements.
Assign principal diagnosis and procedure codes, adhering to coding conventions for proper Ambulatory Payment Classification (APC), Medicare Severity-Drug Related Group (MS-DRG), and APR-DRG assignment.
Demonstrate expertise in CMS HCC Risk Adjustment coding.
Perform chart analysis to identify and address incomplete or inaccurate documentation.
Review and verify medical record information for completeness and accuracy.
Maintain productivity and quality standards, achieving 95% compliance.
Spend 80% of work time assigning codes to inpatient records as a Senior Coding Auditor.
Utilize resources such as Coding Clinic and CPT Assistant to resolve coding issues.
Identify and report coding concerns to supervisors and managers.
Assist in implementing solutions to reduce coding errors.
Stay current on coding and regulatory updates through workshops and educational sessions.
Maintain confidentiality and collaborate effectively with team members.
Communicate clearly and professionally, exercising independent judgment as needed.
Participate in special projects and contribute to organizational procedures as required.
Experience
Minimum of five (5) years of coding experience, with at least four (4) years in inpatient facility coding or a similar role.
Education
High School Diploma or General Education Development (GED) required.
License, Certification, Registration
Required: One of the following certifications:
Registered Health Information Technician (RHIT) Certificate
Coding Specialist Certificate
Registered Health Information Administrator (RHIA) Certificate
Additional Requirements
Previous experience with EMR patient documentation systems.
Advanced knowledge of disease processes, diagnostic procedures, ICD-10-CM, ICD-10-PCS, HCPCS/CPT coding systems, and health information regulations.
Proficiency in medical terminology and pharmacology.
Fluent in English with strong oral and written communication skills.
Strong time management, organizational, and analytical skills.
Ability to manage workload under pressure and meet deadlines independently.
Familiarity with ethical coding standards as defined by AHIMA.
Willingness to undergo a coding skill test during the hiring process.
Preferred Qualifications
Minimum five (5) years of experience in a health information/medical record environment with facility coding experience, including knowledge of Medicare reimbursement guidelines.
Degree in Health Information Management.
Proficiency in EMR systems, Microsoft Office Suite, and other relevant software.
Ability to analyze and interpret statistical data related to productivity and medical record audits.
Extensive knowledge of ICD-10 coding guidelines and CMS HCC Risk Adjustment coding.
Job Type: Full-time
Pay: $27.26 - $32.00 per hour
Schedule: 8-hour shifts
Work Setting: Remote
Employment Type: Full-Time
Seniority level
Mid-Senior level
Employment type
Full-time
Job function
Health Care Provider
Industries
Human Resources Services
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