Job Description
Job Title Coding Specialist
Duration
Location San Antonio,  TX 78214
Other Location
Description Summary:  Evaluates medical record documentation and charge ticket coding to optimize reimbursement by ensuring that diagnostic and procedural codes and other documentation accurately reflect and support the outpatient visit, and to ensure that data comply with legal standards and guidelines.  Interprets medical information such as diseases or symptoms, and diagnostic descriptions and procedures for a given visit in order to accurately assign and sequence the correct ICD-9-CM, HCPCS and CPT codes.
Duties:  All duties performed will be done accurately and in a timely manner.
 
  1. Provides skilled and specialized work in documentation and coding for medical billing of diagnoses and procedures using ICD-9-CM, CPT and HCPCS codes on all patient fee tickets and enter all charges for patient office visits into the vital works computer software.
  2. Review, interpret and assign diagnostic, procedural and evaluation & management codes based upon medical record documentation according to correct coding principles.  Utilizing 1995 & 1997 Documentation Guidelines for Evaluation and Management Services.
  3. Selects correct ICD-9-CM (diagnostic), CPT (procedural) and HCPCS codes based upon interpretation of operative procedure and correct coding principles.  Remains up to date on all coding changes and usage.
  4. Maintain the highest level of professionalism in the communications and interactions with the physicians, nursing, front office, medical records, billing and other departmental staff.
  5. Maintain compliance with Gonzaba Medical Group policies, Official Coding Guidelines and the Gonzaba Medical Group Coder’s Pledge.
  6. Adhere to all confidentiality and HIPAA requirements as outlined  within Gonzaba Medical Group Operating Policies and Procedures in all ways and at all times with respect to any aspect of the data handled or services rendered.
  7. Communicate on a daily basis with your Supervisor/Lead and provide feed-back and updates pertaining to any and all coding or reviews.
  8. Fulfill responsibilities and or duties that may be reasonably provided by Gonzaba Medical Group for the purpose of achieving operational or financial success of the Company.
  9. Undergo quality, accuracy, and reliability testing and adhere to Company polices of such.
  10. Make sure all codes meet all federal, state, legal and insurance regulations so service payment are obtained in a timely manner.
  11. Reviews bulletins, newsletters, and periodicals, and attends workshops to stay abreast of current issues, trends, and changes in the laws and regulations governing medical record coding and documentation; develops and updates procedures manuals to maintain standards for correct coding, minimize the risk of fraud and abuse, and optimize revenue recovery.
  12. Provides queries or technical guidance to physicians and other departmental staff in identifying and resolving issues or errors, such as incomplete or missing records and documentation, ambiguous or nonspecific documentation, or codes that do not conform to approve coding principles/guidelines data in the form of a query, email and or task.
  13. Enhances professional growth and development through membership in professional organizations, participation at in-service meetings/educational programs, and department / division performance improvement activities, and by referencing resource materials.
  14. Maintain credentials and provide copies to your Supervisor/Lead and Human Resources.
  15. Exercise tact and courtesy when dealing with patients, visitors, physicians and co-workers.
  16. Able to work efficiently under pressure.
  17. Maintain strict confidentiality.
  18. Other duties as assigned.
 
Education and Experience:
Minimum high school education or equivalent. Candidates must have Coding Certification by AHIMA (RHIA, RHIT, CCS, CCS-P or CCA) or AAPC (CPC, CPC-H, or CPC-A) preferred.  Eligible to sit for national coding certification through AHIMA or AAPC and must obtain within 90 days of employment.  Have successfully completed a Certified Coding Program; or be a graduate of Health Information Management Program preferred.  3+ years experience in a large outpatient service environment preferred.  Knowledge of ICD-9, CPT, and HCPCS coding systems, guidelines and rules.  Knowledge of billing regulations, medical insurance coverage limitations and managed care protocols.  Knowledge of medical terminology, medical procedures, human anatomy and physiology.  Knowledge of Word processing, database, spreadsheet and Internet software a plus.  Score a minimum of 80% on a pre employment coding test.  Possess the ability to achieve and maintain the designated accuracy rate in coding while adhering to defined production standards.  Demonstrate an increased proficiency in coding and encoder skills within three months.  Strong interpersonal skills and detail oriented.
 
Supervisory Responsibilities:  This job has no supervisory responsibilities.
 
Work Environment:  Depending upon the area assigned, may be 100% clinical setting or office setting in a clinical environment. Exposure to communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations and other conditions common to a clinic environment.
 
Physical Demands:  Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, walking, lifting up to 40 lbs. Close vision and ability to adjust focus.
Required Skills coding specialist
 
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