Under direct supervision, the Hospital Outpatient Coder is responsible for accurate coding and abstracting of diagnoses, conditions, and procedures from medical record documentation for Hospital Ambulatory Surgery, Home Health/Hospice (if applicable), Observation, and Hospital complex Outpatient Visit cases. This role assigns appropriate codes and modifiers using ICD-CM, CPT, and HCPCS Level II codes while following applicable coding rules, regulations, and organizational guidelines.
The position supports timely, accurate, and compliant data abstraction and coding for outpatient services, including cases requiring monitored anesthesia and conscious sedation. The role also involves physician clarification when needed and maintaining confidentiality and security of patient records.
- Review medical records to identify diagnoses and procedures
- Assign diagnosis and procedure codes using standard coding systems
- Sequence codes according to regulatory and payer guidelines
- Abstract and verify data for reporting and submission
- Maintain coding accuracy, productivity, and quality standards
- Protect patient confidentiality and system security
- Two years of continuous hospital coding/abstracting experience within the last five years
- High school diploma or GED
- Completion of coursework in medical terminology, anatomy, physiology, current ICD-CM and CPT coding conventions, and disease process from an accredited program
- One of the following credentials: RHIT, CPC, CCS, CCA, RHIA, or CCS-P
- Minimum score of 75% on the Hospital Outpatient Coder test
- Strong knowledge of anatomy, physiology, medical terminology, and disease processes
- Knowledge of ICD-CM, CPT, HCPCS, Medicare guidelines, and coding/sequencing rules
- Ability to meet productivity and quality standards
- Maintain coding credentials and continuing education requirements
- Compliance with AHIMA and/or AAPC code of ethics
- Must reside in Northern California
Location
California, US
Employment Type
Full-time
Experience Level
Entry Level
Remote work allowed
Yes
Posted
3 weeks ago