Medical Records Coder-Senior

    Highlights

    Provides skilled and specialized technical work in documentation and coding for medical billing, abstracts complex patient-related data from medical records and coding of diagnoses and procedures using ICD-10 and CPT codes. Verifies fee tickets and physician notes for completeness to include abstracting and entering relevant medical information from the medical records; checks for required signatures; assures proper documentation guidelines are followed.

    Numbers & Facts

    LocationSan Antonio, TX

    Description

    Under limited supervision, responsible for conducting the quality review of inpatient and outpatient coding, assures coding compliance with federal regulations, and maintains up-to-date coding guidelines and coding policy changes.

    • Proficiency in ICD-10 and CPT coding.
    • In-depth understanding of medical terminology, anatomy and physiology.
    • Meticulous attention to detail and accuracy.
    • A solid customer service acumen and interpersonal skills to effectively work with both internal and external customers and responds to requests in a timely and respectful manner.
    • Strong verbal, written and interpersonal communication skills.

    Education

    • High school diploma or GED is required.
    • Reviews, interprets, and assigns diagnostic and procedural codes based upon medical record documentation according to correct coding principles.
    • Provides skilled and specialized technical work in documentation and coding for medical billing, abstracts complex patient-related data from medical records and coding of diagnoses and procedures using ICD-10 and CPT codes.
    • Works coding related charge review and claim edits daily to ensure timely and accurate billing.
    • Researches and resolves coding related issues, and assists in meeting productivity and quality standards.
    • Contacts other facilities to obtain medical records and information need to bill for services rendered.
    • Verifies fee tickets and physician notes for completeness to include abstracting and entering relevant medical information from the medical records; checks for required signatures; assures proper documentation guidelines are followed.
    • Interacts with regulator classification agencies and patients when clarification and additional information is required for documentation.
    • Reviews charge documents for completeness.
    • Updates coding books with changes as accepted and published by regulatory agencies.
    • Performs all other duties as assigned.
    • Reviews, interprets, and assigns diagnostic and procedural codes based upon medical record documentation according to correct coding principles.
    • Provides skilled and specialized technical work in documentation and coding for medical billing, abstracts complex patient-related data from medical records and coding of diagnoses and procedures using ICD-10 and CPT codes.
    • Works coding related charge review and claim edits daily to ensure timely and accurate billing.
    • Researches and resolves coding related issues, and assists in meeting productivity and quality standards.
    • Contacts other facilities to obtain medical records and information need to bill for services rendered.
    • Verifies fee tickets and physician notes for completeness to include abstracting and entering relevant medical information from the medical records; checks for required signatures; assures proper documentation guidelines are followed.
    • Interacts with regulator classification agencies and patients when clarification and additional information is required for documentation.
    • Reviews charge documents for completeness.
    • Updates coding books with changes as accepted and published by regulatory agencies.
    • Performs all other duties as assigned.

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