Medical Coder

SUMMARY:

The Certified Medical Coder (CMC) is responsible for reviewing medical claims and provider disputes for patient medical records and assigning accurate diagnostic and procedural codes using ICD-10-CM, CPT, and HCPCS coding systems. This role ensures coding accuracy for billing, reimbursement, and regulatory compliance purposes while maintaining patient confidentiality and adhering to healthcare documentation standards.

RESPONSIBILITIES/TASKS:

· Ensures compliance with all applicable Federal, laws and regulations related to coding and documentation guidelines for Commercial and Medicare Risk Adjustment Payment System.

· Performs medical record review to capture of all relevant diagnosis codes included in the CMS and HHS Hierarchical Condition Categories (HCC) conditions for Commercial and Medicare Risk Adjustment Payment system.

· Ensure diagnosis codes are supported by the documentation and ensure adherence with ICD-10CM Guidelines for Coding and Reporting.

· Apply ICD-10-CM, CPT, and HCPCS Level II coding guidelines correctly and consistently

· Maintain productivity and accuracy standards set by the department

· Stay current with coding updates, guideline changes, and payer-specific requirements

· Collaborate with health management (Utilization Management and Appeals & Grievances) staff to resolve claim denials or coding-related issues

· Protect patient privacy in accordance with HIPAA regulations

· Participate in coding audits and quality assurance reviews

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

EMPLOYMENT QUALIFICATIONS:

EDUCATION:

• PHRN a preference, or equivalent experience.
• Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent certification is required.

EXPERIENCE:

· Minimum two (2) years general coding experience.

· Clinical background preferred, nursing license preferred but not required

· Experience and understanding of CMS HCC Risk Adjustment coding and data validation requirements.

· Initial demonstration and maintenance of continuing education/membership is required.

· Experience and understanding of CMS HCC Risk Adjustment coding and data validation requirements.

SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:

· Excellent organization and problem-solving skills.

· Strong oral and written communication skills.

· Advanced understanding of medical terminology, pharmacology, body systems/anatomy, physiology, and concepts of disease processes.

· Extensive knowledge of ICD-10CM coding guidelines.

· Advanced technical skills for use of MS Office (Excel, Word, Outlook, and PowerPoint) as demonstrated through successful completion of a skills test.

· Demonstrated ability to utilize a variety of electronic medical records systems.

· Ability to manage a significant work load, and to work efficiently under pressure, while meeting established deadlines with minimal supervision.

· Demonstrated ability to communicate clearly and effectively with a wide variety of individuals at all levels of the organization.

· Strong time management skills.

· Must possess a high degree of accuracy, efficiency, and dependability.

· Excellent written and oral communication for representation of clear and concise results.

WORKING CONDITIONS:

• Work is performed remotely
• Day 1 onsite attendance is required for equipment/laptop set up
• Main wired Internet Connection, plus a back up internet is required
• 8:00 AM to 5:00 PM Eastern Shift
• Weekends off allocations rotate

Skills

Business Operations, CPT, Claims Management, Compliance Management, HCPCS, HIPAA, ICD-10-CM, Medical Coding, Medical Terminology, Process Documentation, Quality Management