Inpatient Medical Coder

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

📋 Description

• Review medical records from the emergency department.

• Accurately assign ICD-10-CM diagnosis codes, CPT/HCPCS procedure codes, relevant modifiers, and facility E/M levels.

• Analyze documentation from nursing, physicians, ancillary departments, and diagnostic services to ensure complete coding and charge capture.

• Implement official coding guidelines, CMS regulations, NCCI edits, and specific payer requirements.

• Evaluate procedural services along with injections and infusions.

• Identify any documentation gaps and communicate the need for coding clarifications.

• Ensure compliance with coding policies for Medicare, Medicaid, commercial payers, and the organization.

• Engage in coding quality reviews, audits, educational programs, and initiatives for process improvement.

• Stay informed about updates in coding, reimbursement changes, and regulatory requirements.

• Work collaboratively with coding leadership, auditors, and client representatives to address coding issues.

⛳️ Requirements

• Review emergency department medical records to accurately assign ICD-10-CM diagnosis codes, CPT/HCPCS procedure codes, and applicable modifiers.

• Assign facility Evaluation and Management (E/M) levels correctly, following client-specific guidelines and facility charging methodologies, including proficiency in the ACEP tool.

• Evaluate documentation from nursing staff, physicians, ancillary departments, and diagnostic services to guarantee complete coding and charge capture.

• Apply official coding guidelines, CMS regulations, National Correct Coding Initiative (NCCI) edits, and payer-specific requirements.

• Review accounts to ensure appropriate assignment of procedural services and injections/infusions when necessary.

• Identify documentation deficiencies and communicate effectively through the appropriate channels regarding the need for coding clarifications.

• Maintain adherence to coding policies for Medicare, Medicaid, commercial payers, and the organization.

• Participate in coding quality reviews, audits, educational initiatives, and process improvement activities.

• Stay up-to-date with coding updates, reimbursement changes, and regulatory requirements impacting emergency department facility coding.

• Collaborate with coding leadership, auditors, and client representatives to resolve coding-related issues.

🏝️ Benefits

• Medical, dental & vision coverage.

• Critical Illness, Accident, and Hospital insurance.

• 401(k) Retirement Plan with options for pre-tax and Roth post-tax contributions.

• Life Insurance (Voluntary Life & AD&D for employees and their dependents).

• Short-term and long-term disability coverage.

• Health Spending Account (HSA).

• Transportation benefits.

• Employee Assistance Program.

• Time Off/Leave options (PTO, Vacation, or Sick Leave).