Inpatient Coder

Software Guidance & Assistance, Inc., (SGA), is searching for an Inpatient Coder for a Contract assignment with one of our premier Healthcare clients in working remote EST hours.

Responsibilities :
The Senior Coding Analyst will report to the Manager of Coding and demonstrate expertise in the coding and analysis of pediatric medical records. The Senior Coding Analyst is responsible to review, analyze, and code diagnostic and procedural information for either technical or professional services to determine the care and treatment that was provided to the patient. Will execute coding software accurately and analyze the DRG, APR DRG and AP-DRGs and support the testing of new coding programs. Will act as a resource/contact for all inpatient, outpatient, professional and same day surgery coding.
The primary function of this position is to perform ICD-10-CM/CPT/HCPCS/ICD-10-PCS (IP tech/DRG) coding for Medicare, Medicaid and private insurance payments. The coding function will ensure compliance with established coding guidelines, third party reimbursement policies, regulations and accreditation guidelines.

• Demonstrates excellent organizational and problem-solving skills.
• Ability to communicate professionally with physicians, third party payers and other organization members relative to the coding principles, logic and process.
• Demonstrates the ability to accurately, and completely code the medical record to support reimbursement for services rendered.
• Relies on experience and superior judgment to accomplish goals.
• Possesses a strong understanding of all medical record processes and its contribution to third party reimbursement.
• Maintains confidentiality of the record content at all times.
• Assign and sequence ICD-10-CM/CPT/HCPCS/ICD-10-PCS (IP tech/DRG) codes to diagnose and procedure for documented information. Ensure the final diagnoses and operative procedures as stated by the physician are valid and complete. Abstract all necessary information from health records to identify secondary complications and co-morbid conditions.
• Meet department accuracy and productivity standards for coding, abstracting, and record reconciliation activities.
• Abstract all necessary information and assign ICD-10-CM/CPT/HCPCS/ICD-10-PCS (IP tech/DRG) codes, which most accurately describe each documented diagnosis, surgical procedure and special therapy or procedure according to established guidelines.
• Identify services needing to be abstracted/coded by following prescribed procedures for the capture of inpatient and outpatient services. This may involve the use of admissions, transfer and discharge reports; appointment schedules; and/or surgical schedules.
• Abstract applicable clinical documentation (e.g. admit report, consultation report, progress note, surgical report, etc...) for purposes of determining the appropriate billing information (e.g. provider name, date of service, CPT code, ICD-10 code, modifier(s), etc...).
• Complete appropriate charge documents and submit to appropriate location within specified time frames.
• Ensure all documented services are captured and coded and that all coding work is performed in a manner consistent with applicable coding rules and conventions.
• Analyze processes and data for performance improvement and effectively communicate these findings to the manager .
• Compile and report results of quality review work.
• Perform a comprehensive review of the record to assure the presence of all component parts such as: patient and record identification, signatures and dates where required and other necessary data in the presence of all reports which appear to be indicated by the nature of the treatment rendered.
• Analyze provider documentation to assure the appropriate Evaluation & Management (E & M) levels are assigned using the correct CPT code.
• Evaluate the record for documentation consistency and adequacy. Ensure the final diagnosis accurately reflects the care and treatment rendered.
• Review the records for compliance with established third party reimbursement agencies and special screening criteria.

Required Skills:

• High School Diploma or GED
• Coding certification required: CCS + RHIA, RHIT, CCS, CCS-P, CPC, CIC,COC, CCA, or CPC-A.
• Inpatient Coding experience
• Pediatric coding experience

Preferred Skills:

• Pro/Tech Coding specifically in surgical coding (Colorectal, Neurosurgery, Cardiovascular).

SGA is a technology and resource solutions provider driven to stand out. We are a women-owned business. Our mission: to solve big IT problems with a more personal, boutique approach. Each year, we match consultants like you to more than 1,000 engagements. When we say let's work better together, we mean it. You'll join a diverse team built on these core values: customer service, employee development, and quality and integrity in everything we do. Be yourself, love what you do and find your passion at work. Please find us at .

SGA is an Equal Opportunity Employer and does not discriminate on the basis of Race, Color, Sex, Sexual Orientation, Gender Identity, Religion, National Origin, Disability, Veteran Status, Age, Marital Status, Pregnancy, Genetic Information, or Other Legally Protected Status. We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, and our services, programs, and activities. Please visit our company to request an accommodation or assistance regarding our policy.
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