Job Title: Outpatient Facility Medical Coder
Location: Onsite Portland, OR, US
Employment Type: Permanent, Full-Time
Salary: As per Exp.
As an Outpatient Facility Medical Coder , you will independently assign accurate diagnosis and procedure codes to patient health records for various healthcare settings including Emergency Department (ED), Ambulatory Surgical Center (ASC), Hospital Ambulatory Surgical Center (HAS), Observations (OBS), Inpatient (IP), and other selected facility records. You will ensure adherence to official coding guidelines and maintain high standards of quality and productivity in ICD-10-CM, ICD-10-PCS, and HCPCS/CPT coding systems. This role requires on-site presence for training for at least one week or until departmental expectations are met.
Essential Responsibilities:Coding & Data Management: Review medical records and accurately assign codes for diagnoses, procedures, and services rendered. Validate Computer Assisted Coding (CAC) assignments for dual coding.
Systems Utilization: Utilize Code Base Charge Trigger system (CBCT) and OPTUM 360 EncoderPRO software for professional surgical services. Access patient encounter information via EpicCare.
Quality Assurance: Perform thorough quality checks to ensure accuracy and compliance with CMS coding guidelines, NCCI, UHDDS, OMAP, and Client coding directives.
Clinical Data Abstraction: Identify and assign principal diagnosis and procedure codes, sequencing them for proper APC, MS-DRG, and APR-DRG assignment.
Chart Analysis & Documentation: Regularly review charts to identify incomplete or inaccurate documentation. Ensure compliance with CMS coding rules and guidelines.
Knowledge Maintenance: Stay current on coding regulations, trends, and best practices by reviewing ICD-10 Official Guidelines, Coding Clinic updates, and CPT Assistant publications.
Collaboration & Reporting: Participate in staff meetings, coding in-services, and quality outcome monitoring. Assist with special projects and implement solutions to reduce coding errors.
Ethics & Confidentiality: Maintain confidentiality and uphold the standards of ethical coding as set by the American Health Information Management Association (AHIMA).
Experience: Minimum 2 years of experience in a directly related coding field or 18 months within the Kaiser Apprentice program.
Education: High School Diploma or GED required.
Licenses/Certifications: Must have one of the following:
Registered Health Information Administrator (RHIA)
Registered Health Information Technician (RHIT)
Certified Coding Specialist (CCS)
Proficiency in ICD-10-CM, ICD-10-PCS, HCPCS/CPT coding systems .
Advanced knowledge of disease processes, diagnostic and surgical procedures, and medical coding principles.
Familiarity with EMR patient documentation systems (e.g., EpicCare) and coding software.
Proficient in Microsoft Office Suite and related software.
Excellent time management, organizational, and analytical skills .
Ability to work independently under pressure and meet established deadlines.
Strong communication skills with fluency in English (oral and written).
Ability to apply independent judgment and adhere to ethical coding standards.
Must pass a coding skill test with a score of 75% or higher .
Minimum 2 years of experience in a health information or medical record environment, with facility coding experience including Medicare reimbursement guidelines.
Degree in Health Information Management .
Advanced knowledge of ICD-10 coding guidelines, CMS HCC Risk Adjustment coding, and data validation requirements .
Ability to analyze productivity trends and medical record audits using mathematical statistics and percentages.
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