Job Description

Location: Remote

Job Summary:

We are looking for a detail-oriented Clinical Coder / Medical Records Specialist to join our team. The successful candidate will be responsible for reviewing clinical documentation, diagnostic results, and medical records to accurately assign ICD-9-CM/ICD-10-CM/PCS and CPT-4 codes. This role plays a critical part in ensuring regulatory compliance, reimbursement, and accurate external reporting for inpatient and outpatient records.

Key Responsibilities:

• Review clinical documentation and diagnostic results to extract and abstract data, applying appropriate ICD-9-CM/ICD-10-CM/PCS and CPT-4 codes.
• Code and abstract medical records of high complexity within acute care facilities.
• Identify and assign the correct principal diagnosis, secondary diagnoses, and procedure codes in compliance with guidelines.
• Assign Present on Admission (POA), Hospital Acquired Condition (HAC), and Core Measure Indicators for all diagnosis codes.
• Facilitate appropriate MS-DRG assignment for inpatient records and APC assignment for outpatient records using UHDDS and facility guidelines.
• Use the facility encoder as it interfaces with the hospital's mainframe and/or EMR in an on-site or remote setting.
• Review charges and evaluate management levels for accuracy.
• Abstract coded data and relevant information in the hospital's electronic health records (EHR) system.
• Ensure the accuracy of data input and meet established quality and productivity standards.
• Facilitate peer review and training for all Acute Clinical Coders in the coding department.
• Stay current with coding principles and regulatory guidelines for both inpatient and outpatient coding.
• Provide support to management as needed.

Qualifications:

• Certification in Medical Coding (e.g., CPC, CCS, RHIT, or RHIA) required.
• Proven experience in clinical coding, preferably in an acute care setting.
• Proficiency in ICD-9-CM/ICD-10-CM/PCS, CPT-4 coding, and UHDDS guidelines.
• Experience with facility encoders, EMR systems, and Microsoft Office Applications.
• Strong attention to detail and ability to maintain high accuracy in a fast-paced environment.
• Excellent communication and interpersonal skills for peer training and support.
• Ability to sit and concentrate for long periods while reviewing electronic health records.

Work Environment:

This role may be performed in a fast-paced office environment or remotely, with daily and weekly deadlines that must be met.

If you are interested, qualified, available, planning to make a change, or know of a friend who might have the required qualifications and interest, please call me ASAP at (732) 290-4745 even if we have spoken recently about a different position. If you do respond via e-mail please include a daytime phone number so I can reach you.

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