Job Description

Job Description

Job Description

Job Description: We are seeking an experienced Medical Coder III with advanced expertise in coding medical services for inpatient coding. This role involves assigning codes for professional and institutional services in inpatient discharges, consultations, and surgical procedures. The ideal candidate will review documentation, correct discrepancies, and collaborate closely with auditors and clinical staff to ensure coding accuracy and compliance with health regulations.

Minimum Qualifications:

• Education : Completion of one of the following:

  • Associate’s degree or higher in Health Information Management, Healthcare Administration, or biological sciences.
  • University certificate in medical coding.
  • At least 30 semester hours of university/college credits that include relevant coursework (anatomy/physiology, medical terminology, health information management, and/or pharmacology).
  • Completion of an AAPC or AHIMA coding certification preparation course for professional services or facility coding.
  • Advanced training course for medical technicians, hospital corpsmen, medical service specialists, or military training obtained in the Armed Forces or U.S. Maritime Service.

• Certification :

• At least one recognized professional coding certification, such as:

  • Certified Professional Coder (CPC), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA),

  • or Certified Coding Specialist – Physician (CCS-P ). and ONE of the following:

    • Certified Outpatient Coder (COC), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA),

  • or Certified Coding Specialist (CCS), AND ONE of the following recognized E&M coding certifications:

    • Certified Evaluation and Management Coder (CEMC), or National Alliance of Medical Auditing Specialists’ (NAMAS) Certified Evaluation and Management Auditor (CEMA).

• Additional Requirements :

  • U.S. Citizenship.
  • Bilingual in English and Spanish.

Core Duties:

• Accurately assigns Evaluation and Management (E&M) codes, International Classification of Diseases, Clinical Modification (ICD-CM) diagnoses, ICD-10 Procedure Coding System (ICD-10-PCS), Current Procedural Terminology (CPT), Healthcare Common Procedure Coding System (HCPCS), modifiers, and quantities derived from medical record documentation (paper or electronic) for the professional and institutional (facility) components of inpatient facility discharges (stays); inpatient professional services to include attending (also known as “Rounds”), consultations, and concurrent services, and inpatient surgical and anesthesia procedures; and inpatient External Resource Sharing Agreement (ERSA) encounters. May also code ambulatory (i.e. Coder II) or outpatient (i.e. Coder I) encounters as directed.

  • Reviews encounter and/or record documentation to identify and resolve inconsistencies, ambiguities, or discrepancies that may cause inaccurate coding, medico-legal repercussions or impacts quality patient care.

  • Identifies any problems with legibility, abbreviations, etc., and brings to the provider’s attention.

  • Educates and provides feedback to providers and clinical staff to resolve documentation issues to support coding compliance.

  • Assigns accurate codes to encounters based upon provider responses to coding queries.

  • Acts as a source of reference to medical staff having questions, issues, or concerns related to coding. Responds to provider questions and provides examples of appropriate coding and documentation reference(s) to provide clarity and understanding. Collaborates with and supports medical coding auditors, trainers, and compliance specialists in providing education and feedback to providers and staff.

  • Supports DHA coding compliance by performing due diligence in ethically and appropriately researching and/or interpreting existing guidance, including seeking clarification through appropriate channels.

  • Upon DHA-MCPB direction, utilizes MHS computer systems to remotely access patient records and assign codes for patient encounters in support of other MTFs.

  • Achieve and maintain DHA coding productivity and accuracy standards for the position.

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