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Certified Coder
<p><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">This position is responsible for reviewing clinical documentation and applying the correct coding and modifiers for clinical services performed in office and/or hospital setting an may include surgical and non-surgical procedural services. This position ensures that the documentation supports the levels or types of service billed, ensures the documentation is compliant with regulatory regulations, provider documentation guidelines, and CPT documentation and CMS coding guidelines</span></p><p><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"=""><strong>Job Relationships</strong></span></p><p><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">Reports to the Coding Unit Manager</span></p><p><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"=""><strong>Principal Responsibilities</strong></span></p><ul><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">Responsible for reviewing and analyzing documentation present in the medical record for professional services related to clinic, inpatient and/or outpatient services. </span></li><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">Verifying and coding of the diagnosis, evaluation and management, procedures or other codes required for the completeness and accuracy of the record. </span></li><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">Codes and/or reviews encounters to identify first-listed diagnosis, co-morbidities, complications, therapeutic and diagnostic procedures with International Classification of Diseases (ICD10), Current Procedural Terminology (CPT), Heath Care Financing Administration Common Procedure Coding Systems (HCPCS – all levels, and any other coding classification systems that may be required).</span></li><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">Examine all documents in the record for authorized signature and patient identification to ensure all documents contain sufficient documentation to support the diagnosis and treatment administered, and the results obtained are adequately described.</span></li><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">Communicates with hospitals/physicians to obtain additional documentation when needed to complete coding documentation requirements.</span></li><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">Responsible for charges to be posted in a timely fashion as directed by the Manager.</span></li><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">Assist other staff employees as necessary including training fellow coders in specialties of expertise.</span></li><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">Assist the Director or Manager with all projects in related scope of job knowledge and responsibility.</span></li><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">Comply with the Springfield Clinic incident reporting policy and procedures.</span></li><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">Adhere to all OSHA and Springfield Clinic training & accomplishments as required per policy.</span></li><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">Provide excellent customer service and adhere to Springfield Clinic's Code of Conduct and Ethics Standards.</span></li><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">Perform other job duties as assigned.</span></li></ul><p><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"=""><strong>Education/Experience</strong></span></p><ul><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">High School graduate or GED minimum required: College degree in health-related field preferred. </span></li><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">Coding experience in Professional & Facility Coding</span></li><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">2 years of experience as a certified coder preferred</span></li></ul><p><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"=""><strong>Licenses/Certificates</strong></span></p><ul><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">Must have one of the following AHIMA or AAPC certifications: CPC, CCS, CCS-P, RHIT, RHIA</span></li></ul><p><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"=""><strong>Knowledge, Skills and Abilities</strong></span></p><ul><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">Expert knowledge of CPT, HCPCS, E/M leveling, Modifiers and ICD-10-CM diagnostic coding required. </span></li><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">Proficient computer skills using MS-Word, Excel, PowerPoint, Outlook, Teams, Microsoft Edge, and EncoderPro.</span></li><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">Preferred knowledge using Athena, Ingenious Med and RCX.</span></li><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">Utilize Official Guidelines for Coding and Reporting, Coding Clinics and CPT for coding accuracy. </span></li><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">Provide excellent customer service internal and external and adhere to Springfield Clinic's Code of Conduct and Ethics Standards.</span></li><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">Strong analytical and communication skills.</span></li><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">Attend, as directed, conferences, in-services and workshops toward further professional development and job knowledge.</span></li><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">Maintain credentialing CEUs </span></li><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">Follow all Clinic operation procedures and policies.</span></li></ul><p><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"=""><strong>Working Environment</strong></span></p><ul><li><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">In office, remote optional based off productivity/accuracy standards</span></li></ul><p><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"=""><strong>PHI/Privacy Level</strong></span></p><p><span style="font-family:" calibri",sans-serif;font-size:9.0pt;"="">HIPAA1</span></p>