Job Description

Location: Remote (must be able to work in EST)

Schedule: Monday - Friday, 8:00 AM - 4:00 PM; 1 weekend day required, any shift

Job Summary:

We are seeking a highly skilled and detail-oriented Medical Coder to accurately assign, sequence, and abstract ICD-9-CM and CPT-4 codes for various patient visit types, including inpatient, same-day surgery, ambulatory surgery, endoscopy, outpatient, and emergency department visits. This individual will be responsible for assigning the correct Diagnostic Related Group (DRG) to discharged patients' records and abstracting all necessary data into the hospital's computer system.

Key Responsibilities:

• Assign and sequence ICD-9-CM and CPT-4 codes for inpatient, same-day surgery, ambulatory surgery, endoscopy, outpatient, and emergency patient visits.
• Assign accurate DRG to discharged patient records and abstract data into the hospital's computer system.
• Meet productivity standards:
• 24 inpatient records per 7.5-hour workday, averaging 2 inpatient records per hour.
• 6-8 same-day surgery, ambulatory procedure, or endoscopy records per hour.
• 10-12 Emergency Department records per hour.
• Interact daily with physicians and their offices to clarify and verify questions, resolve coding/documentation issues, and ensure accurate coding.
• Conduct internal coding studies and provide coding-related resource information to departments such as Administration, Billing, Finance, Quality, Care Management, and CDI.
• Run daily reports for ER and SDC patients to ensure medical necessity compliance and collaborate with the Billing Department regarding medical necessity issues.
• Collect unbilled and uncoded patient accounts as part of the Health Information Management Department's performance improvement plan and report findings monthly to the Director.
• Stay up to date with the latest coding guidelines through attendance at in-services, seminars, and other relevant training opportunities.
• Required Skills and Qualifications:
• Inpatient hospital coding experience and Certified Coding Specialist (CCS) certification is required.
• Strong understanding of ICD-9-CM, CPT-4, DRGs, and coding standards.
• Ability to meet established productivity standards and maintain accuracy in coding.
• Excellent communication skills, especially when interacting with physicians and other medical staff.
• Ability to work independently and collaborate effectively across departments.
• Knowledge of medical necessity compliance, NCDs, and LCDs.

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