Professional Billing Charge Capture

Primary Responsibilities

• Leverage understanding of disease process to identify and extract relevant details and data within clinical documentation and make determinations or identify appropriate medical codes
• Utilize resources and reference materials (e.g., on-line sources, manuals) to identify appropriate medical codes and reference code applicability, rules, and guidelines
• Apply understanding of relevant medical coding subject areas (e.g., diagnosis, procedural, evaluation and management, ancillary services) to assign appropriate medical codes
• Apply understanding of basic anatomy and physiology to interpret clinical documentation and identify applicable medical codes
• Identify areas in clinical documentation that are unclear or incomplete and generate queries to obtain additional information
• Follow up with providers as necessary when responses to queries are not provided in a timely basis
• Utilize medical coding software programs or reference materials to identify appropriate codes
• Read and interpret medical coding rules and guidelines to make decisions (e.g., exclusions, sequencing, inclusions)
• Make determinations on medical charting and take initiative to complete reviews independently to avoid delays in the process
• Apply relevant Medical Coding Reference, Federal, State, and Professional guidelines to assign and record independent medical code determinations
• Manage multiple work demands simultaneously to maintain relevant productivity and turnaround time standards for completing medical records (e.g., charts, assessments, visits, encounters)
• Provide information or respond to questions from medical coding quality audits
• Perform medical coding audits to evaluate medical coding quality
• Review medical coding audit results - Follow steps per agreement with medical coding audit results to resolve discrepancies
• Provide resources and information to substantiate medical coding audit findings
• Education and mentor others to improve medical coding quality
• Leverage relevant computer software programs (e.g., Microsoft Office) to record information, analyze data, or communicate with others
• Utilize and navigate across clinical software applications to assign medical codes or complete reviews

Required Qualifications

• A High School Diploma / GED
• 2+ years of experience with documentation for procedures, supplies and E&M levels (including ED, OB and OBS)
• Intermediate level of Microsoft Office experience
• Intermediate level of EHR experience, specifically with Epic

Preferred Qualifications

• Certified Coder with credentials from AAPC with a CPC or AHIMA with CCS, RHIT, RHIA

Soft Skills

• Meet metric expectations
• Good communication skills
• Team player