Certified Coder

Responsible for reviewing clinical documentation and applying the correct coding and modifiers for services performed in office and/or hospital settings, including surgical and non-surgical procedural services. Ensures documentation supports billed levels and types of service and complies with regulatory requirements, provider documentation guidelines, CPT documentation, and CMS coding guidelines.

Key Responsibilities

• Review and analyze documentation in the medical record for professional services related to clinic, inpatient, and/or outpatient services.
• Verify and code diagnoses, evaluation and management services, procedures, and other required codes for completeness and accuracy.
• Code and/or review encounters to identify first-listed diagnosis, comorbidities, complications, therapeutic and diagnostic procedures using ICD-10, CPT, HCPCS, and other applicable coding systems.
• Examine records for authorized signatures and patient identification to ensure sufficient documentation supports diagnosis and treatment.
• Communicate with hospitals and physicians to obtain additional documentation when needed.
• Ensure charges are posted in a timely manner as directed by management.
• Assist other staff as needed, including training fellow coders in areas of expertise.
• Support the Director or Manager with projects related to job scope and responsibility.
• Follow Springfield Clinic incident reporting policies and procedures.
• Adhere to OSHA requirements and Springfield Clinic training and policy standards.
• Provide excellent customer service and follow the organization's Code of Conduct and Ethics Standards.
• Perform other duties as assigned.