Position Summary
We are seeking experienced and credentialed Outpatient Medical Coders to join our healthcare coding team. This role is responsible for reviewing outpatient medical records, assigning accurate diagnosis and procedure codes, and ensuring compliance with all applicable coding guidelines, payer regulations, and industry standards.
The ideal candidate is detail-oriented, highly productive, technologically proficient, and capable of maintaining a high level of coding accuracy while working independently in a remote environment.
Key Responsibilities
Medical Coding & Documentation Review
- Review and interpret outpatient health record documentation, including radiology, laboratory, and ancillary service encounters.
- Assign accurate ICD-10-CM, CPT, and HCPCS codes based on provider documentation.
- Maintain a minimum coding accuracy rate of 95%.
- Apply current Evaluation & Management (E&M) guidelines for outpatient encounters.
- Assign appropriate modifiers and ensure compliance with Correct Coding Initiative (CCI) guidelines.
- Verify that multiple CPT codes are not components of a more comprehensive procedure that should be reported with a single code.
- Associate diagnoses, procedures, and rendering providers accurately within the electronic health record system.
- Identify encounters created in error or encounters lacking sufficient documentation and flag them for review.
- Determine billable status and identify reasons encounters may not be billable.
- Ensure all coding assignments comply with current coding regulations, payer requirements, and industry standards.
Compliance & Quality Assurance
- Adhere to HIPAA, privacy, security, and confidentiality requirements.
- Follow the AHIMA Standards of Ethical Coding and all applicable professional coding standards.
- Utilize available coding resources and references to ensure accurate code assignment.
- Identify and escalate conflicting, ambiguous, or incomplete documentation through established channels.
- Maintain compliance with annual privacy and security training requirements.
- Properly safeguard and dispose of any printed medical records or protected health information.
Productivity Expectations
- Process a minimum of 90 outpatient encounters per 8-hour workday while maintaining quality standards.
- Demonstrate flexibility to support multiple outpatient service lines and coding specialties as business needs require.
Required Knowledge & Skills
- Strong understanding of ICD-10-CM, CPT, HCPCS, and Evaluation & Management coding guidelines.
- Knowledge of Correct Coding Initiative (CCI) bundling and modifier application.
- Ability to accurately identify diagnoses, procedures, and services from clinical documentation.
- Knowledge of reimbursement methodologies and healthcare compliance requirements.
- Familiarity with outpatient billing regulations and non-billable encounter determination.
- Strong analytical, organizational, and problem-solving skills.
- Excellent written and verbal communication skills.
- Ability to work independently in a remote environment while meeting productivity and quality standards.
Required Education & Credentials
Candidates must possess one or more of the following active coding credentials:
AHIMA Certifications
- RHIA — Registered Health Information Administrator
- RHIT — Registered Health Information Technician
- CCS — Certified Coding Specialist
- CCS-P — Certified Coding Specialist – Physician-based
AAPC Certifications
- CPC — Certified Professional Coder
- CPC-H — Certified Professional Coder – Hospital
Additionally:
- Completion of an accredited coding, health information management, or health information technology program is required.
- Minimum of two years of outpatient and/or inpatient coding experience required.
Technical Requirements
- Experience working within electronic health record systems.
- Experience with Oracle Cerner and Federal EHR systems preferred.
- Proficiency with coding software, encoders, and healthcare information systems.
- Strong computer skills and ability to learn new technologies quickly.
- Dedicated home office or workspace free from distractions.
- Dual-monitor setup required.
- Reliable high-speed internet connection required.
Work Environment
- Fully remote position.
- Independent contractor opportunities may be available based on project needs.
- Candidates must maintain professional standards, confidentiality, and productivity expectations while working remotely.
