Clinical Coder / Medical Records Specialist

Job Title : Clinical Coder / Medical Records Specialist

Location : Remote

Job Summary :

We are looking for a detail-oriented Clinical Coder / Medical Records Specialist to join our team. The successful candidate will be responsible for reviewing clinical documentation, diagnostic results, and medical records to accurately assign ICD-9-CM / ICD-10-CM / PCS and CPT-4 codes. This role plays a critical part in ensuring regulatory compliance, reimbursement, and accurate external reporting for inpatient and outpatient records.

Key Responsibilities :

• Review clinical documentation and diagnostic results to extract and abstract data, applying appropriate ICD-9-CM / ICD-10-CM / PCS and CPT-4 codes.
• Code and abstract medical records of high complexity within acute care facilities.
• Identify and assign the correct principal diagnosis, secondary diagnoses, and procedure codes in compliance with guidelines.
• Assign Present on Admission (POA), Hospital Acquired Condition (HAC), and Core Measure Indicators for all diagnosis codes.
• Facilitate appropriate MS-DRG assignment for inpatient records and APC assignment for outpatient records using UHDDS and facility guidelines.
• Use the facility encoder as it interfaces with the hospital's mainframe and / or EMR in an on-site or remote setting.
• Review charges and evaluate management levels for accuracy.
• Abstract coded data and relevant information in the hospital's electronic health records (EHR) system.
• Ensure the accuracy of data input and meet established quality and productivity standards.
• Facilitate peer review and training for all Acute Clinical Coders in the coding department.
• Stay current with coding principles and regulatory guidelines for both inpatient and outpatient coding.
• Provide support to management as needed.

Qualifications :

Work Environment :

This role may be performed in a fast-paced office environment or remotely, with daily and weekly deadlines that must be met.

If you are interested, qualified, available, planning to make a change, or know of a friend who might have the required qualifications and interest, please call me ASAP at (732) 290-4745 even if we have spoken recently about a different position. If you do respond via e-mail please include a daytime phone number so I can reach you.