Job Description
Overview
The Coder III reviews clinical documentation and diagnostic results and applies appropriate ICD-10-CM, ICD-10-PCS, and CPT codes to support diagnoses, procedures, and treatment results. Codes are used for billing, internal and external reporting, research, and regulatory compliance activities. Abides by the standards of Ethical Coding as set forth by the American Health information Management Association (AHIMA) and adheres to all official coding guidelines. This role is remote.
Responsibilities
- Verifies that all ICD-10-CM and CPT codes are correctly captured.
- Verifies that physician is correctly abstracted.
- Keeps abreast of coding guideline changes by self-study, assigned education, coding meeting attendance or related in-services.
- Participates in internal and external quality review meetings.
- Resolves billing related errors and assists with workflow changes and process improvement projects.
- Meets ongoing productivity and quality standard of 95% accuracy rate or better.
- Assigns codes for diagnoses, treatment, and procedures for inpatient surgeries as applicable.
- Determines the correct principal diagnosis, co-morbidities, complications, secondary conditions, and surgical procedures.
- Abstracts correctly all required information from records including discharge disposition and OSHPD required information.
- Assigns the correct MS-DRG and APR-DRG and correct Present on Admission (POA) indicators and identifies Hospital Acquired Conditions (HAC).
- Queries physicians per established policy and procedure when documentation is not clear or conflicting.
Qualifications
- High school diploma or equivalent required.
- Completion of a certified coding program or graduate of a CAHIM accredited HIT program required.
- Five years of progressive inpatient coding experience in an acute care facility.
Certifications
- Certified Coding Specialist (CCS)
Employment details
- Employment type: Full-time
- Seniority level: Mid-Senior level
- Location: Orange, CA (remote role)
Job function & Industry
- Job function: Health Care Provider
- Industries: Hospitals and Health Care
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Job Tags
Full time,