Certified Inpatient/Outpatient Medical Coder

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct thorough reviews of electronic medical records to ensure coding completeness, accuracy, and compliance.

• Examine operative reports, anesthesia records, progress notes, discharge summaries, diagnostic reports, and other relevant documentation.

• Identify and assign appropriate principal and secondary diagnoses as well as procedures.

• Utilize ICD-10-CM, ICD-10-PCS, CPT, HCPCS, Evaluation and Management, and other relevant coding standards.

• Ensure that diagnoses and procedures are accurately documented, coded, and sequenced appropriately.

• Recognize complications, comorbid conditions, present-on-admission indicators, CC/MCC conditions, and other elements that influence reimbursement and reporting.

• Review both inpatient and outpatient records across various medical specialties.

• Prepare compliant queries for physicians or clinicians when documentation is conflicting, incomplete, or unclear.

• Maintain precise diagnostic and procedural information utilized for clinical, statistical, billing, and reimbursement purposes.

• Provide reports and briefings to designated Government representatives as required.

⛳️ Requirements

• Candidates must possess at least one current certification from AHIMA or AAPC, such as: Registered Health Information Technician - RHIT, Certified Coding Specialist - CCS, Certified Coding Specialist–Physician Based - CCS-P, Registered Health Information Administrator - RHIA, Certified Professional Coder - CPC.

• Must be a United States citizen.

• Proficient in both spoken and written English.

• Minimum of three years of continuous medical coding experience.

• Coding experience within a hospital or healthcare facility with a large and diverse patient population.

• Proven experience in both inpatient and outpatient medical coding.

• Capability to review and code complex medical, surgical, diagnostic, and procedural records.

• Familiarity with Oracle Cerner, 3M/Solventum, ICD-10-CM/PCS, CPT, E/M, and HCPCS.

🏝️ Benefits

• Safeguard patient information while adhering to all privacy, cybersecurity, and information security regulations.

• Engage in audits, scheduled and unscheduled reviews, performance monitoring, corrective actions, and retraining as necessary.

• Keep abreast of current knowledge regarding CMS, VA, VHA, HIPAA, coding, billing, and regulatory requirements.