Outpatient Facility Medical Coder

The Outpatient Facility Medical Coder is responsible for accurately assigning diagnosis and procedure codes to patient health information records across various departments. This role requires independent and efficient performance while maintaining high levels of quality and productivity in accordance with ICD-10-CM, ICD-10-PCS, and HCPCS/CPT coding systems and regulations. The position involves one (1) week of on-site training or until the department's expectations are met. 

• Proficiently review medical records and translate clinical information into coded data. 
• Assign appropriate codes for diagnoses, procedures, and services rendered. 
• Utilize electronic patient data systems and clinical information systems effectively. 
• Abstract and enter clinical data elements as required by organizational needs. 
• Assign principal diagnosis and procedure codes, sequencing them accurately for proper classification. 
• Review and verify chart information to ensure completeness and accuracy of documentation. 
• Analyze medical records to identify incomplete, inaccurate, or inconsistent documentation. 
• Stay updated on coding and regulatory publications, participate in coding education sessions. 
• Assist in implementing solutions to reduce coding errors. 
• Maintain confidentiality and foster effective working relationships with staff. 
• Communicate clearly and effectively, exercising independent judgment. 
• Perform additional duties as assigned. 

Requirements

Basic Qualifications

• Minimum two (2) years of experience in a directly related coding field or 18 months within the Kaiser Apprentice program. 
• High School Diploma or General Education Development (GED) required. 
• One of the following certifications: Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist (CCS). 
• Previous experience with EMR patient documentation systems and intermediate computer skills. 
• Advanced knowledge of disease processes, diagnostic and surgical procedures, and coding systems. 
• Fluent in English, with strong oral and written communication skills. 
• Strong time management, organization, and analytical skills. 
• Ability to manage a significant workload efficiently under pressure with minimal supervision. 
• Adherence to the Standards of Ethical Coding set by AHIMA. 

Preferred Qualifications: 

• Minimum two (2) years of experience in health information/medical record environment, with facility coding experience including Medicare reimbursement guidelines. 
• Proficient knowledge and skill in computer usage and related systems/software. 
• Extensive knowledge of ICD-10 coding guidelines, CMS HCC Risk Adjustment coding, and data validation requirements. 
• Degree in Health Information Management. 

Benefits

Remote work option available after satisfactory on-site training. Room for professional growth, comprehensive health insurance, pension plan, and retirement package provided.