Hospital Coder 2 (Experienced) - Health Information Management - Full Time

Summary

Reviews a variety of reports for clinical and demographic information, assigns appropriate ICD-10-CM diagnosis codes and/or CPT/HCPC procedure codes and enters this information into the electronic system for the purpose of maintaining a complete and accurate clinical data base. Production coding is primarily responsible for performing advanced coding of outpatient hospital services, including Emergency Department/Urgent Care encounters, Observation/IV administration, Outpatient in a Bed, Ambulatory Surgery, and Ancillary/Recurring accounts. This role ensures accurate, complete, and compliant assignment of ICD-10-CM, CPT, and HCPCS codes in accordance with AMA, CMS, and official coding guidelines. Audits provider documentation to ensure compliance with documentation and coding guidelines.

Utilizes both manual and AI-assisted coding platforms to optimize accuracy, compliance, and throughput. Ensures data integrity for quality reporting, population health, and financial reimbursement purposes.

Queries providers for clarifying documentation and other documentation as needed.

Education

Minimum: High school diploma or equivalent required.

Preferred: Associate degree in Health Information Technology or related field.

Certification, Registration & Licensure

Required: Certified Coding Specialist (CCS), Certified Coding Specialist Physician (CCS-P), Certified Inpatient Coder (CIC), or Certified Outpatient Coder (COC) (AHIMA or AAPC).

Preferred: Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT).

CPC credentialed coders with hospital-based experience may be considered.

Experience

Minimum 1 year of recent hospital coding experience required.

Responsibilities

• Analyze electronic medical record to identify all episodes of care, extracts demographic and clinical documentation and applies accurate codes based on ICD-10-CM/AMA guidelines, Concord Hospital policies, and CMS local/national coding rules.

• Processes work to meet or exceed departmental productivity and quality targets, consistent with industry standards.

• Demonstrates competency to perform role by completing yearly competency testing related to a combination of organizational compliance education, departmental operations and regulatory coding standards.

• Uses encoder (3M) with Coders Desk Reference, CPT Assistant, and AHA Coding Clinics reference tools to enhance standardization, quality and consistency.

• Queries physicians when documentation is incomplete, unclear, or inconsistent, following CDI and query compliance guidelines.

• Prioritizes and manages daily work queues to support DNFB reduction and timely billing.

• Protects patient privacy and ensures data integrity in compliance with HIPAA and facility policies.

• Participates in internal/external audits and responds to coding denials or compliance reviews with appropriate documentation to support code assignment.

• Maintains continuing education and credentials by completing required CEU education focused on current knowledge of coding updates, regulatory guidance (CMS, AMA), and Coding Clinic releases.

• Review claim edits and front-end billing rejections in real-time to resolve coding issues and minimize delays in billing.

• Attend and contribute to coder education huddles, team meetings, coding update reviews, and training sessions via online platforms.

• Present a professional image in all virtual communications, meet deadlines, and maintain availability during scheduled working hours.

• Ensure workstations and remote systems function properly for virtual meetings, screen sharing, and communication platforms (e.g., Teams, Zoom, Outlook) to maintain active engagement with leads, peers, and auditors. Promptly follow established IT protocols to report and resolve any technical issues or software malfunctions.

• Demonstrate flexibility by coding in multiple outpatient areas (e.g., ED, ASC, radiology, recurring therapies) based on department needs.

• Collaborates with Management, Coding Resource team, and IT to resolve coding/documentation-related workflow issues or barriers to work completion.

• Demonstrates a commitment to ethical coding practices, teamwork, and continuous improvement.

Knowledge and Skills

• Solid understanding of official coding guidelines, including CPT, HCPCS, and ICD-10-CM, and how they apply to outpatient coding workflows.

• Strong grasp of medical terminology, human anatomy, disease processes, pharmacology, and the interpretation of clinical test results.

• Ability to adapt quic