Role overview
Turn clinical documentation into accurate, compliant codes for outpatient, inpatient, professional fee, or specialty encounters.
Key responsibilities
- Review provider notes, operative reports, lab and imaging results, and discharge summaries to capture the full clinical picture and appropriate level of service.
- Assign E/M levels, DRGs, and risk adjustment (HCC) codes that reflect patient complexity and withstand payer and audit scrutiny.
- Follow official coding guidelines, NCCI edits, LCD/NCD rules, and payer-specific policies.
- Query providers when documentation is unclear and help improve documentation through practical education.
- Work coding queues and denials in systems such as Epic, Cerner/Oracle Health, 3M 360 Encompass, Optum Encoder, and athenahealth.
- Research and resolve claim edits, rejections, and coding-related denials in partnership with billing and revenue cycle teams.
- Support internal and external audits with clear rationale for every code assigned.
- Protect patient privacy under HIPAA and follow secure remote work practices.
- Use CAC and AI-assisted tools carefully, applying professional judgment to all final coding decisions.
- At senior levels, handle complex charts, mentor coders, lead audits and education, and support coding policy and process decisions.
Requirements & Qualifications
Required qualifications
- Working knowledge of medical terminology, anatomy and physiology, and ICD-10-CM, CPT, and HCPCS coding.
- Hands-on coding experience from a job, externship, internship, practicum, or coursework with real practice charts.
- Strong attention to detail and the ability to meet accuracy and productivity goals.
- Clear written communication for provider queries and effective teamwork.
- Ability to work independently from home with reliable high-speed internet and a quiet workspace.
- Certificate, diploma, or degree in Health Information Management, Medical Coding, Health Sciences, or a related field, or equivalent experience.
- Authorization to work in the United States.
Preferred qualifications
- Active certification such as CPC, CCS, CCS-P, CCA, CRC, COC, or CIC, or progress toward one.
- Experience with Epic, Cerner, 3M, Optum, or similar encoders and CAC tools.
- Specialty experience in surgery, cardiology, orthopedics, oncology, emergency, radiology, or behavioral health.
- Knowledge of risk adjustment, HCC, MS-DRG, APC, or value-based care coding.
- Experience with denials management, coding audits, or clinical documentation improvement (CDI).
- Familiarity with Medicare, Medicaid, and commercial payer requirements.
- Associate or bachelor’s degree in Health Information Management or RHIT eligibility.
- Background in hospitals, physician groups, ambulatory surgery centers, urgent care, home health, behavioral health, payers, or coding vendors.
Location
Texas, US
Employment Type
Full-time
Experience Level
Senior
Salary Range
$50,000 - $75,000
Remote work allowed
Yes
Posted
2 weeks ago
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