About the job
We are seeking an experienced Inpatient Facility Medical Coder to join our team in Seattle. This role involves independently and efficiently assigning accurate diagnosis and procedure codes to patient health information records across various departments including Emergency Department (ED), Ambulatory Surgical Center (ASC), Hospital Ambulatory Surgical Center (HAS), Observations (OBS), and Inpatient (IP) records. The ideal candidate will maintain high standards of quality and productivity for ICD-10-CM, ICD-10-PCS, and HCPCS/CPT classification systems while adhering to the established coding guidelines set forth by CMS, NCHS, AMA, NCCI, UHDDS, Medicaid, and Kaiser Permanente. Effective communication with physicians to clarify diagnoses and procedures is essential. Successful completion of on-site training for one week is required to meet departmental expectations.
Essential Responsibilities:
- Conduct thorough medical record reviews and translate clinical information into precise coded data.
- Identify and assign accurate codes for diagnoses and procedures, validating Computer Assisted Coded (CAC) assignments for dual coding.
- Utilize the Code Base Charge Trigger system (CBCT) and OPTUM 360 EncoderPRO software for professional surgical services, ensuring the accuracy and validity of coding systems.
- Access patient encounters using the EpicCare electronic patient data system.
- Abstract and enter clinical data elements as per the organizational needs.
- Determine principal diagnosis and procedure codes, sequencing them for proper APC and MS-DRG assignments while following applicable coding conventions.
- Demonstrate knowledge of CMS HCC Risk Adjustment coding and routinely perform chart analysis to identify incomplete or inconsistent documentation.
- Ensure the completeness and accuracy of medical records in compliance with CMS coding rules and guidelines.
