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The coder will apply classification standards to medical records, perform quality assessments, and resolve documentation discrepancies. They will also support management by educating staff and creating executive summaries based on audit findings.
Duties and Responsibilities:
Apply appropriate coding classification standards and guidelines to medical record documentation for accurate coding and documentation reviews.
Help create and review provider queries to resolve documentation discrepancies.
Support manager with providing education regarding appropriate documentation and code applications.
Perform quality assessment of records, including verification of medical record documentation.
Review appropriate charges and make changes or recommendations based on the documentation.
Responsible for researching errors or missing documentation from medical records to provide accurate coding processes.
Assist with organizing and maintain auditing logs for multiple clients and people.
Create executive summaries based on findings, including recommendations for next steps.
Be comfortable working with executives, physicians, and members of the C-suite.
Knowledge, Skills, and Abilities:
Must have facility, professional, and critical access auditing experience and ideally be exposed to observation hours, injections, and infusion code assignment.
Must be able to assist in educating coders, providers, and clinical staff.
Must be comfortable working with AR teams to resolve issues.
Must be able to pass a coding assessment.
Must be proficient in Microsoft Office, including Outlook, Excel, and Teams.
Ability to multi-task and have excellent communication skills.
Must meet and maintain a 95% quality accuracy rate and productivity standards.
Must be able to apply official coding guidelines, NCCI edits, CPT Assistants, and Coding Clinics.
Must have experience working in a remote environment.
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