Medical Coder

Location: Work from home (Pennsylvania) Shift: Days (United States of America) Scheduled Weekly Hours: 40 Worker Type: Regular Exemption Status: No Job Summary: Health information coding is the transformation of verbal descriptions of diseases, injuries, and procedures into numeric or alphanumeric designations. The coding process reviews and analyzes health records to identify relevant diagnoses and procedures for distinct patient encounters. Coders are responsible for translating diagnostic and procedural phrases utilized by healthcare providers into coded form procedure codes that can be utilized for submitting claims to payers for reimbursement. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures. Job Duties: Reviews the content of the medical record for hospital and professional inpatient or outpatient records to identify principal diagnosis, secondary diagnoses and procedures performed that explain the reason for service being provided or the admission and patient severity and comply with standard provider coding regulations. Carefully details review of documents such as laboratory findings, radiology reports, various scan reports, discharge summary, history and physical, consultations, orders, progress notes and other ancillary services treatment records needed to ensure all pertinent diagnoses and procedures are recorded. Translates all diagnostic and procedural phrases utilized by healthcare providers into coded form using procedure codes as required. Using the Encoder software program, determines the codes for all diagnoses and procedures. Determines their sequencing to legally maximize reimbursement. Assigns the appropriate DRG. Assigns codes based on hospital and professional coding guidelines, Coding Clinic directives, federal regulations, CCI coding initiatives, CPT Assistant or other standard coding guidelines Queries physici