Overview

Full-time Monday through Friday 8:00am to 4:30pm

Remote (must live in Florida).

The Coder III position assigns diagnoses and procedure codes to inpatient medical records.

Responsibilities

• Assigns correct ICD-10-CM code to all diagnoses and correct ICD-10 PCS code to all procedures documented in the medical record.
• Thoroughly reviews the entire medical in order to retrieve proper documents (i.e. discharge summary, progress notes, operative report, pathology report, anesthesia report, etc.) to provide coding specificity.
• Assesses documentation to ensure it is adequate and appropriate to support the diagnoses and procedures to be abstracted.
• Selects the principal diagnosis and procedure according to the Uniform Health Data Discharge Set definitions and coding rules published in Coding Clinic.
• Sequences codes within regulatory guidelines for correct DRG assignment.
• Accurately abstracts attending and operating physicians in the Sunrise Record Manager abstracting system.
• Verifies and corrects appropriate discharge disposition.
• Maintains a thorough knowledge of the use of the encoder to assist in code assignment.
• Queries physicians as necessary to resolve documentation discrepancies. Maintains a positive working relationship with physicians in order to improve coder clinical competency and educate the clinician on documentation practice issues.
• Maintains a thorough knowledge of the prospective payment system and any new codes or DRG’s added/changed each year. Adheres to all official guidelines as approved by the Cooperating Parties (AHA, AHIMA, CMS, NCHS) as well as the ICD-9-CM coding conventions, Coding Clinic, and other official recourses to substantiate the most appropriate, correct code assignment. Stays abreast of Medicare’s medical review policies and incorporates updates and changes into the coding process.

Qualifications

Education / Training

• High School Diploma/Equivalent

Preferences:

Graduate of Health Information Management Program

Experience Requirements

• 5 to 7 years Hospital Medical Record Coding

Certificates/Licenses/Registration

• Certified Coding Specialist (CCS)

Additional Information:

Certified Coding Specialist (CCS) certification by AHIMA required.

Education / Training

• High School Diploma/Equivalent

Preferences:

Graduate of Health Information Management Program

Experience Requirements

• 5 to 7 years Hospital Medical Record Coding

Certificates/Licenses/Registration

• Certified Coding Specialist (CCS)

Additional Information:

Certified Coding Specialist (CCS) certification by AHIMA required.

• Assigns correct ICD-10-CM code to all diagnoses and correct ICD-10 PCS code to all procedures documented in the medical record.
• Thoroughly reviews the entire medical in order to retrieve proper documents (i.e. discharge summary, progress notes, operative report, pathology report, anesthesia report, etc.) to provide coding specificity.
• Assesses documentation to ensure it is adequate and appropriate to support the diagnoses and procedures to be abstracted.
• Selects the principal diagnosis and procedure according to the Uniform Health Data Discharge Set definitions and coding rules published in Coding Clinic.
• Sequences codes within regulatory guidelines for correct DRG assignment.
• Accurately abstracts attending and operating physicians in the Sunrise Record Manager abstracting system.
• Verifies and corrects appropriate discharge disposition.
• Maintains a thorough knowledge of the use of the encoder to assist in code assignment.
• Queries physicians as necessary to resolve documentation discrepancies. Maintains a positive working relationship with physicians in order to improve coder clinical competency and educate the clinician on documentation practice issues.
• Maintains a thorough knowledge of the prospective payment system and any new codes or DRG’s added/changed each year. Adheres to all official guidelines as approved by the Cooperating Parties (AHA, AHIMA, CMS, NCHS) as well as the ICD-9-CM coding conventions, Coding Clinic, and other official recourses to substantiate the most appropriate, correct code assignment. Stays abreast of Medicare’s medical review policies and incorporates updates and changes into the coding process.