Outpatient Coder I, Ambulatory - Physician Services

About the position At Hackensack Meridian Health, the Outpatient Coder I plays a crucial role in ensuring accurate coding and data abstraction for outpatient services. This position is integral to the healthcare process, as it involves the application of the Official International Classification of Diseases (ICD)-10-Clinical Modification (CM), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS) guidelines. The coder is responsible for accurately abstracting patient data and entering it into the electronic medical record system, ensuring compliance with Centers for Medicare and Medicaid Services (CMS) directives. The role requires a keen eye for detail and a strong understanding of clinical documentation, as the coder must assess medical records, identify deficiencies, and communicate with healthcare providers to obtain necessary information for proper coding. The Outpatient Coder I will be expected to assign codes to clinical services performed, which are essential for reimbursement and data collection. This includes coding for diagnostic, surgical, and procedural information, as well as identifying reportable elements and complications. The coder will also monitor work queues for billing corrections and maintain productivity and quality standards as set by Hackensack Meridian Health. This position is remote, and experience in Orthopedics and Oncology coding is strongly preferred, highlighting the specialized nature of the coding work involved. In addition to coding responsibilities, the Outpatient Coder I must comply with organizational policies and standards of behavior, report any unusual circumstances or discrepancies to management, and participate in other assigned projects. This role is designed for entry-level candidates who possess a high school diploma or GED and have a foundational understanding of coding practices, making it an excellent opportunity for those looking to start their career in medical coding.

Responsibilities

• Assign codes to clinical services performed for use in reimbursement and data collection.

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• Accountable for coding and abstracting of patient encounters, including diagnostic, surgical, and procedural information, significant reportable elements, and complications.

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• Assess clinical documentation and communicate with physicians and advanced practice nurses for additional information when documentation for proper coding is missing or incomplete.

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• Analyze medical records and identify documentation deficiencies.

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• Identify reportable elements, complications, and other quality measures.

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• Daily monitoring of work queues for billing corrections.

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• Assign CPT, HCPCS and ICD-10-CM codes.

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• Knowledge of and ability to address National Correct Coding Initiative (NCCI) and National Coverage Determinations (NCD) / Local coverage determinations (LCD) edits.

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• Maintain required productivity and quality requirements.

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• Comply with HMH Organizational policies, procedures, and standards of behavior; maintain patient records.

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• Report unusual circumstances, possible risk factors, errors, and discrepancies to management.

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• Perform other duties and/or projects as assigned.

Requirements

• High School diploma or GED equivalent.

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• Minimum of 1 year of coding for professional services.

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• Strong understanding of physiology, medical terms, and anatomy.

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• Proficiency in computer skills including typing speed and accuracy.

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• Excellent written and verbal communication skills.

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• Proficient in Microsoft Office and Google Suite platforms.

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• Ability to achieve and maintain appropriate coding quality and productivity as established by HMH Compliance Education.

Nice-to-haves

• Prior working experience with outpatient hospital ICD10 diagnosis, CPT procedural and E&M coding experience is desired.

Benefits

• Competitive benefits package including health insurance and retirement plans.

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• Supportive work culture focused on connection and collaboration.

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• Opportunities for professional development and career advancement.

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