Facility Medical Coder -Outpatient
Listed on 2026-01-18
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Healthcare
Medical Billing and Coding, Medical Records
Job Description Summary
Under general supervision and according to established procedures, assigns diagnostic codes as well as EM leveling for facility to medical record information. The Coder I is responsible for accurate and timely assignment of codes to diagnoses and procedures for all Facility Outpatient cases including but not limited to same day surgery, Emergency Room and Observations. Using established department policies and procedures in conjunction with the current version of ICD-CM Classification for Hospitals, the Coder I will assign the most appropriate codes for OPPS.
Coder I will utilize their experience and knowledge to determine the correct first list diagnosis, , secondary diagnoses, CPT procedure codes and secondary procedure codes. The Coder I is empowered at South Shore Hospital to query providers when documentation requires clarification and he/she proactively works with HIM and medical leadership to address concerning documentation trends. The Coder I works with direct support from and under the direction of the HIM Coding Manager to make certain their skills and knowledge remain in peak condition.
As a vital member of our respected team the Coder I will work collaboratively with other areas of the Health Information Management department and the Clinical Documentation Integrity unit to advance the profession and reinforce the valuable contributions coders make to the care delivery system.
ESSENTIAL FUNCTIONS
- Codes ____ (# determined according to type of record coded) records per hour, consistently with 95% accuracy.
- Maintains within five (5) days after discharge coding requirements.
- Verifies that coded information is entered into the databases without any errors within five (5) days of patient discharge.
- Identifies any documentation inadequacies with physician and/or appropriate parties and clarifies medical record information with courtesy and tact.
- Assists physicians and ancillary departments with coding questions with timeliness, courtesy and tact.
- Utilizes professional affiliations, etc., in order to maintain current in professional developments.
- Attends all pertinent coding seminars.
- Maintains updated coding books.
Equivalent to an Associate's Degree in Medical Information Technology (with course work in medical terminology, anatomy, physiology, disease processes, ICD-10-CM coding and prospective payment) preferred.
Minimum Work ExperienceSix to twelve (6–12) months of experience preferred.
Required CertificationsCCS or COC - Certified Coding Specialist OR Certified Outpatient Coder
Required additional Knowledge and AbilitiesEligible for designation as a RHIT, RHIA preferred.
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