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Coding and Documentation:
- Review clinical documentation from physician and hospital services to assign accurate ICD-10, CPT, and HCPCS codes for diagnoses, procedures, and services.
- Ensure that coding practices comply with federal, state, and local regulations, as well as payer-specific guidelines.
- Work with healthcare providers to clarify ambiguous or conflicting documentation, ensuring accurate and complete coding.
- Enter and validate coded data in the electronic health record (EHR) and billing systems.
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Compliance and Quality Assurance:
- Perform coding audits to ensure accuracy and compliance with coding standards and regulations.
- Identify and report any coding discrepancies or issues to the Coding Supervisor or Medical Coding Director.
- Stay current with coding updates, guidelines, and payer requirements to ensure ongoing compliance.
- Participate in continuing education and training to maintain coding certifications and stay informed of industry changes.
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Collaboration and Communication:
- Collaborate with clinical staff, physicians, and other healthcare professionals to ensure accurate coding and documentation practices.
- Provide feedback and education to providers on documentation improvement and coding best practices.
- Assist with resolving coding-related billing issues, denials, and rejections in collaboration with the billing and revenue cycle teams.
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Data Management and Reporting:
- Ensure timely and accurate entry of coded data into the EHR and other relevant systems.
- Generate coding reports as needed for management, audit, or quality improvement purposes.
- Participate in special coding projects or assignments as directed by management.
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Education:
- High school diploma or equivalent is required.
- Associate’s degree in Health Information Management, Nursing, or a related field is preferred.
- Certification as a Certified Coding Specialist (CCS-P), Certified Professional Coder (CPC)
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Experience:
- A minimum of 2-5 years of experience in medical coding, with experience in both physician and hospital coding preferred.
- Demonstrated knowledge of ICD-10, CPT, and HCPCS coding systems for both inpatient and outpatient services.
- Experience in coding for a variety of medical specialties and service lines, including complex cases.
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Skills:
- Proficiency in using coding software and electronic health record (EHR) systems.
- Strong understanding of medical terminology, anatomy, and physiology.
- Excellent attention to detail and accuracy in coding and data entry.
- Ability to work independently and manage multiple priorities in a fast-paced environment.
- Strong communication skills, with the ability to collaborate effectively with healthcare providers and other team members.
- Commitment to ongoing education and professional development to maintain coding certifications and stay current with industry standards.
- Ability to work in a dynamic healthcare environment with a focus on accuracy, compliance, and efficiency.
- Strong ethical standards and commitment to maintaining patient confidentiality and data security.
- Prolonged periods sitting at a desk and working on a computer.
- Must be able to lift up to 15 pounds at times.
Pay: $24.00 - $26.00 per hour