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About the role
Key responsibilities & impact- Health information coding is the transformation of verbal descriptions of diseases, injuries, and procedures into numeric or alphanumeric designations.
- Coders are responsible for translating diagnostic and procedural phrases utilized by healthcare providers into coded form procedure codes that can be utilized for submitting claims to payers for reimbursement.
- Reviews the content of the medical record for hospital and professional inpatient or outpatient records to identify principal diagnosis, secondary diagnoses and procedures performed that explain the reason for service being provided or the admission and patient severity and comply with standard provider coding regulations.
- Carefully details review of documents such as laboratory findings, radiology reports, various scan reports, discharge summary, history and physical, consultations, orders, progress notes and other ancillary services treatment records needed to ensure all pertinent diagnoses and procedures are recorded.
- Translates all diagnostic and procedural phrases utilized by healthcare providers into coded form using procedure codes as required.
- Using the Encoder software program, determines the codes for all diagnoses and procedures.
- Queries physicians as needed to clarify documentation within the patient’s record to facilitate complete and accurate coding.
- Communicates to Coding Quality and Professional Manager any new diagnoses, procedures, technologies, etc. documented within patient records to ensure that appropriate diagnosis and procedure codes are selected and incorporated into hospital and professional coding guidelines.
Requirements
What you’ll need- Certification requirement for Coder II and above: One relevant certification from AHIMA or AAPC is required upon hire. Acceptable certifications include: All certifications are acceptable from AAPC (American Academy of Professional Coders) except: Scribe, Documentation, Instructor, and International Credentials
- Certified Professional Biller (CPB)
- Revenue Cycle Management Specialist (RCMS)
- Certified Value-Based Administrator (CVBA)
- Certified Physician Practice Manager (CPPM)
- Certified Professional Compliance Officer (CPCO)
- Certified Coding Specialist (CCS)
- Certified Coding Specialist – Physician-based (CCS-P)
- Registered Health Information Technician (RHIT)
- Registered Health Information Administrator (RHIA)
- Certified Coding Associate (CCA) – Candidates with only a CCA are required to obtain a CCS, RHIT, or RHIA within 12 months of hire.
- High School Diploma or Equivalent (GED)- (Required)
- Graduate from Specialty Training Program- (Preferred)
- Minimum of 1 year-Related work experience (Required)
Benefits
Comp & perks- We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners
- We encourage an atmosphere of collaboration, cooperation and collegiality.
ATS Keywords
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Hard Skills & Tools
health information codingdiagnostic codingprocedure codingmedical record reviewcoding regulationsencoder softwaredocumentation clarificationcoding guidelinesreimbursement codingpatient severity coding
Soft Skills
communicationattention to detailanalytical thinkingproblem-solvingcollaboration
Certifications
Certified Professional Biller (CPB)Revenue Cycle Management Specialist (RCMS)Certified Value-Based Administrator (CVBA)Certified Physician Practice Manager (CPPM)Certified Professional Compliance Officer (CPCO)Certified Coding Specialist (CCS)Certified Coding Specialist – Physician-based (CCS-P)Registered Health Information Technician (RHIT)Registered Health Information Administrator (RHIA)Certified Coding Associate (CCA)