Lead CDI Coder

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

📋 Description

• Accurately assign diagnostic codes based on documented information, ensuring adherence to regulatory standards and that the assigned codes accurately reflect the clinical information noted by the provider.

• Ensure that documentation supports the appropriate level(s) of care and severity of illness when applying ICD-10, CPT, and other relevant codes for billing and regulatory compliance.

• Maintain a productivity rate of 95%.

• Communicate with physicians and other healthcare professionals to clarify documentation, ensuring that diagnoses and procedures are documented in accordance with clinical standards.

• Issue queries to healthcare providers when documentation appears ambiguous, incomplete, or inconsistent, requesting clarification or additional details to be added to the medical record for accurate documentation.

• Ensure that the queries comply with industry standards and regulatory guidelines.

• Stay informed about the latest coding guidelines, clinical protocols, and regulatory changes, including Medicare and Medicaid billing and coding guidelines, to support provider compliance.

• Assist in enhancing the quality of clinical documentation to support various quality initiatives, such as HEDIS, CMS, and other performance metrics initiated by contracts or enterprises.

• Participate in performance improvement projects focused on enhancing documentation practices and outcomes.

• Conduct audits of medical records to identify trends in documentation, both positive and negative, to assist the organization in improving documentation practices and provider education efforts.

• Provide ongoing education for clinical staff, coders, and other healthcare providers regarding best practices in clinical documentation, coding guidelines, and regulatory compliance.

• Develop training programs aimed at addressing documentation deficiencies and enhancing overall documentation quality.

• Collaborate with departments such as compliance, revenue cycle, and quality management to optimize the documentation improvement process.

• Perform other duties related to this role as assigned.

⛳️ Requirements

• High school diploma, GED, or an equivalent qualification.

• 3+ years of recent experience in outpatient medical coding.

• Must hold one of the following coding credentials: CPC, CRC, CCS, CPMA, or a similar certification.

• Strong understanding of ICD-10-CM, Category II, and CPT coding.

• Proficient in medical terminology, anatomy, and physiology.

• Familiarity with healthcare laws, regulations, and applicable guidance, including Medicare, Medicaid, HEDIS, and CMS performance measures.

• Knowledge of risk adjustment methodology and Hierarchical Condition Categories (HCC).

• Ability to analyze complex medical records, identify documentation gaps, and formulate appropriate queries.

• Excellent written and verbal communication skills.

• Impeccable attention to detail to ensure a high level of accuracy in work products.

• Ability to identify discrepancies in clinical documentation and collaborate with providers to resolve issues effectively.

• Proficient with electronic health records (EHR), CDI software, and healthcare documentation systems is essential.

• Intermediate skills with MS Office Suite products, including Outlook and Teams.

• Capable of working effectively in a primarily remote environment.

🏝️ Benefits

• Paid time off starting at 4 weeks for full-time employees.

• 12 paid holidays each year.

• Medical, dental, vision, and life insurance, including an HSA with employer match.

• Reimbursement for continuing medical education for eligible roles.

• A 401(k) program with Evergreen matching up to 4% of contributions after six months of tenure.

• Paid parental leave.

• A comprehensive training and development program that begins with onboarding and continues throughout your career with Evergreen Nephrology.