• Job Description

  Req#: 47651
  Overview
  
  

  Position: Coder III
  FTE: Full-time
  Shift Hours: Monday – Friday, 8:00 AM – 4:30 PM
  Work Location: Remote (must reside in Florida)

  Position Summary:
  The Coder III is responsible for assigning diagnoses and procedure codes to inpatient medical records. The role ensures accurate coding to support proper billing, reimbursement, and compliance with regulatory requirements.

  
  Responsibilities
  
  

  • Key Responsibilities:

    • Assign correct ICD-10-CM codes to all diagnoses and ICD-10-PCS codes to all procedures documented in the medical record

    • Thoroughly review the medical record to retrieve proper documentation, including discharge summaries, progress notes, operative reports, pathology reports, anesthesia reports, etc., to ensure coding specificity

    • Assess documentation to ensure it is adequate and appropriate to support diagnoses and procedures

    • Select the principal diagnosis and procedure according to Uniform Health Data Discharge Set definitions and coding rules published in Coding Clinic

    • Sequence codes within regulatory guidelines for correct DRG assignment

    • Accurately abstract attending and operating physicians in the Sunrise Record Manager abstracting system

    • Verify and correct discharge dispositions as appropriate

    • Maintain thorough knowledge of the encoder system to assist in code assignment

    • Query physicians as necessary to resolve documentation discrepancies and maintain positive working relationships to improve clinical competency

    • Stay current on the prospective payment system, new codes, and annual DRG changes

    • Adhere to all official coding guidelines (AHA, AHIMA, CMS, NCHS), Coding Clinic, and other resources to ensure accurate code assignment

    • Incorporate Medicare medical review policy updates into the coding process

  
  Qualifications
  
  

  Education / Training:

  • High School Diploma or equivalent (required)

  • Preferred: Graduate of a Health Information Management program

  Experience Requirements:

  • 5 to 7 years of hospital medical record coding experience

  Certificates / Licenses / Registration:

  • Any AAPC or AHIMA Medical Coding Certification

  
  

  Education / Training:

  • High School Diploma or equivalent (required)

  • Preferred: Graduate of a Health Information Management program

  Experience Requirements:

  • 5 to 7 years of hospital medical record coding experience

  Certificates / Licenses / Registration:

  • Any AAPC or AHIMA Medical Coding Certification

  
  

  • Key Responsibilities:

    • Assign correct ICD-10-CM codes to all diagnoses and ICD-10-PCS codes to all procedures documented in the medical record

    • Thoroughly review the medical record to retrieve proper documentation, including discharge summaries, progress notes, operative reports, pathology reports, anesthesia reports, etc., to ensure coding specificity

    • Assess documentation to ensure it is adequate and appropriate to support diagnoses and procedures

    • Select the principal diagnosis and procedure according to Uniform Health Data Discharge Set definitions and coding rules published in Coding Clinic

    • Sequence codes within regulatory guidelines for correct DRG assignment

    • Accurately abstract attending and operating physicians in the Sunrise Record Manager abstracting system

    • Verify and correct discharge dispositions as appropriate

    • Maintain thorough knowledge of the encoder system to assist in code assignment

    • Query physicians as necessary to resolve documentation discrepancies and maintain positive working relationships to improve clinical competency

    • Stay current on the prospective payment system, new codes, and annual DRG changes

    • Adhere to all official coding guidelines (AHA, AHIMA, CMS, NCHS), Coding Clinic, and other resources to ensure accurate code assignment

    • Incorporate Medicare medical review policy updates into the coding process

• About the company

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