Outpatient Facility Medical Coder with RHIT/RHIA (Remote for WA/OR ONLY)

About the role

The role involves independently and efficiently assigning accurate diagnosis and procedure codes to various health information records across different facilities including ED, ASC, HAS, OBS, IP, and others. The position adheres to official coding guidelines from CMS and NCHS, as well as AMA CPT, NCCI, UHDDS, Medicaid (OMAP), and institutional coding directives.

Responsibilities

• Proficient in medical record review and translating clinical information into coded data.
• Identify and assign appropriate codes for diagnoses, procedures and other services rendered, validating CAC assignments.
• Utilize CBCT and OPTUM 360 EncoderPRO software for professional surgical services, ensuring system accuracy and validity.
• Access patient encounter information through EpicCare and abstract clinical data elements as per organizational needs.
• Abstract and enter clinical data elements, ensuring completeness and accuracy of diagnostic and therapeutic procedures.
• Perform chart analysis to identify incomplete, inaccurate or inconsistent documentation, and verify POS and attending provider information.
• Review and verify component parts of medical records to ensure compliance with CMS coding rules and guidelines.
• Maintain 95% department standards for productivity and quality.
• Research coding issues using Coding Clinic, CPT Assistant, and other resources, and inform supervisors of coding concerns.
• Assist in reducing back-end coding errors and implement solutions to improve coding accuracy.
• Stay updated on coding and regulatory publications, attend workshops, and maintain confidentiality.
• Participate in coding in-services, staff meetings, reporting of performance measures, and quality outcome monitors.
• May assist with special projects and coding education sessions.

Requirements

• Minimum two years experience in coding field or 18 months within the Apprentice program.
• High School Diploma or GED.
• Licenses, Certifications, Registrations: Registered Health Information Technician Certificate, Registered Health Information Administrator Certificate.
• Previous experience with EMR patient documentation system and intermediate knowledge of computer use.
• Advanced knowledge of disease processes, diagnostic and surgical procedures, ICD-10-CM, ICD-10-PCS, HCPCS/CPT, classification systems, and government regulations.
• Fluent in English, demonstrating skill and proficiency in oral and written communication.
• Skills in time management, organization, and analytical skills.
• Ability to manage a significant workload, meet deadlines, and work efficiently under pressure.
• Independent thought and judgement.
• Abides by the Standards of Ethical Coding as set for by AHIMA.
• Pass a coding skill test with a score of 75% or better.
• Academic knowledge and working experience in coding and abstracting responsibilities in health information/medical record services.

Qualifications

• Minimum two years experience in health information/Medical record environment, with facility coding experience that includes Medicare reimbursement guidelines.
• Proficient knowledge and skill in the use of a computer and related systems and software, including EMR(s), Microsoft Office Suite, and other software programs.
• Ability to evaluate, analyze, and develop information regarding mathematical statistics and percentages to compare findings, trends, and outcomes related to productivity and medical record audits.
• Extensive knowledge of ICD-10 coding guidelines; understanding of CMS HCC Risk Adjustment coding and data validation requirements.
• Preferred: Degree in Health Information Management.