Senior Coder

About the role

Performs coding and abstracting duties to assure accurate completion of coding for all assigned patient records.

Responsibilities

• Analyzes and interprets the medical record in its entirety to ensure accurate, complete, and consistent selection of diagnoses and procedures for quality healthcare data and accurate facility payment.
• Applies understanding of basic anatomy and physiology to interpret clinical documentation and identify applicable codes.
• Utilizes resources and reference materials (e.g., manuals, online resources: Official Coding Guidelines (OCG), AHA Coding Clinic, Center for Medicare Services, and CPT Assistant) to identify appropriate codes and reference code applicability, rules, and guidelines.
• Applies the Uniform Hospital Discharge Data Set (UHDDS) definitions and regulatory guidelines to select the principal diagnosis, secondary diagnoses, all significant procedures, indicating the patient's acuity, severity of illness, and risk of mortality (if applicable).
• Codes and reports diagnoses and their associated Present on Admission (POA) Indicator and procedures.
• Accurately assigns discharge disposition for all records in accordance with Centers for Medicare and Medicaid Services (CMS) rules and regulations.
• Manages multiple work demands simultaneously to maintain efficiency and turnaround time standards for completing coding/DRG assignment.
• Assigns and reports all other data elements required for Statewide Planning and Research Cooperative System (SPARCS) data collection, Congenital Malformations, and Expirations.
• For outpatient encounters, applies coding conventions and official coding guidelines approved by Current Procedural Terminology (CPT) rules established by the American Medical Association (AMA).
• Assigns appropriate discharge physician in the system.
• Generates compliant physician queries to clarify incomplete, ambiguous, or conflicting documentation and applies post-query responses to make final coding determinations.
• Demonstrates basic knowledge of the impact of coding decisions on the revenue cycle.
• Assists in educating physicians and other clinicians on proper documentation practices to reflect acuity, severity of illness, and risk of mortality accurately.
• Attends and participates in required hospital education programs to maintain and enhance coding skills and stay updated on changes in codes, guidelines, and regulations.
• Completes moderately complex assignments requiring occasional deviation from accepted practices and exercises independent judgment on basic or moderately complex issues.
• Works independently under minimal supervision within established guidelines and procedures, requiring minimal instruction on day-to-day work.
• Works with lead on resolution of day-to-day technical or procedural challenges.
• May provide work guidance to team members to ensure accurate and timely completion of tasks.
• Performs related duties as required.

Qualifications

• High School Diploma or equivalent, required.
• 3-5 years of technical experience required.
• Certified Coding Specialist (CCS), Certified Professional Coder (CPC), Certified Coding Specialist-Physician (CCSP), Certified Inpatient Coder (CIC), Certified Outpatient Coder (COC), Certified Coding Associate (CCA), RHIA, or RHIT certification, required.

Pay

The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget, and internal equity).