31 documentation coding auditor jobs found

Purpose Statement The Certified Coder will play a key role in converting diagnoses and treatment procedures into ICD-10, CPT and HCPCS codes. The Coder will review and accurately code office and hospital procedures for reimbursement. Job Type Full-time Description The Certified Coder will be responsible for coding patient encounters, abstracting diagnostic and procedural information, and ensuring accurate reimbursement based on clinical documentation. Essential Functions Accounts for coding and abstracting of patient encounters, including diagnostic and procedural information, significant reportable elements, and complications. Researches and analyzes data needs for reimbursement. Analyzes medical records and identifies documentation deficiencies. Serves as resource and subject matter expert to other coding staff. Reviews and verifies documentation supports diagnoses, procedures, and treatment results. Identifies diagnostic and procedural information. Audits clinical...

Perm - Remote - Hospital Inpatient Coder As a permanent, remote Hospital Inpatient Coder, you will be responsible for accurately coding inpatient medical records, ensuring compliance with coding guidelines, and collaborating with healthcare professionals to maintain data integrity, all while working from home. Essential Job Functions: Assign ICD10CM and PCS codes to hospital inpatient visits Reviews and analyzes the content of medical records and the autosuggested computer assisted codes (CAC) for the appropriate assignment of ICD diagnosis/procedure codes, present on admission indicators, hierarchical condition categories, complication and comorbidities in the proper sequence in accordance with official coding resources resulting in an accurate DRG assignment. Meets 95% accuracy rate in audits Maintains productivity of 2.75 charts per hour after release from training period. Data Analysis- Hospital Inpatient Coding Accurately reviews and codes patient records in the...

Inpatient Coder (Remote) Full-time Work From Home Must have CCS, RHIA, or RHIT certification Job Summary As a Coding Integrity Specialist III WORK FROM HOME, you will review and evaluate hospital inpatient medical record documentation to assign, sequence, edit and/or validate the appropriate ICD-10-CM and ICD-10-PCS codes. A CIS III performs coding and/or code/DRG validation across multiple entities by applying all appropriate coding guidelines and criteria for code selections. Job Qualifications Assign, sequence, validate, and/or edit codes/DRGs and abstracted data (e.g., physician, discharge disposition, query tracking) for inpatient records for multiple facilities using ICD-10-CM and ICD-10-PCS Maintain or exceed established accuracy standards Maintain or exceed established productivity standards Utilize the complete patient medical record documentation in code/DRG assignment, validation, and/or editing of codes/DRGs Undergraduate (Associate's or Bachelor's)...

Inpatient Coder The Inpatient Coder is responsible for accurately assigning ICD-10-CM and ICD-10-PCS codes to inpatient medical records, ensuring compliance with coding guidelines, reimbursement policies, and corporate standards. This role supports Health Information Management (HIM) Central Services and works to review inpatient documentation, apply accurate codes, and collaborate with clinical documentation integrity (CDI) teams to optimize coding accuracy and financial integrity. Essential Functions Performs remote inpatient coding for CHS-supported hospitals, reviewing electronic medical records (EMR) and provider documentation to assign accurate diagnosis and procedure codes. Ensures compliance with ICD-10-CM and ICD-10-PCS coding guidelines, payer-specific rules, and regulatory requirements. Submits queries to providers for documentation clarification when necessary to ensure coding specificity and clinical accuracy. Collaborates with CDI teams to ensure complete,...

Senior Inpatient Coder - Remote Under direct supervision, accurately codes hospital inpatient accounts for the purpose of appropriate reimbursement, research, statistics, and compliance to federal and state regulations in accordance with established ICD-10-CM/PCS coding classification systems. Serves as a clinical coding subject matter expert, and utilizes critical thinking to analyze and evaluate documentation issues with consultation from the medical and clinical staff, and clinical documentation specialists as needed. Analyzes, codes, and abstracts complex inpatient cases such as trauma, rehab, neurology, critical care, etc. utilizing the ICD-10-CM and ICD-10-PCS nomenclature to ensure accurate APR-DRG/SOI/ROM and POA assignment. Utilizes critical thinking to analyze and evaluate documentation issues with consultation from the medical and clinical staff, and clinical documentation specialists as needed. Collaborates with other senior coders (and the other coding staff)...

Base pay range $30.00/hr - $37.00/hr Job Title: Remote Inpatient Medical Coder & Inpatient Team Lead Location: 100% Remote (Must reside in the Central Time Zone ) Schedule: Monday – Friday | 8:00 AM – 4:30 PM CT Employment Type: Full-Time Federal Contract Duration: Long-term Role Overview We are seeking experienced Inpatient Medical Coders and a high-performing Inpatient Team Lead for a high-volume facility within the VA healthcare system. These are fully remote positions requiring a high level of investigative accuracy and a deep understanding of complex inpatient documentation. Note: Previous experience within the VA, a University Medical Center, or a Teaching Hospital is mandatory. Core Responsibilities Medical Coding: Review complex inpatient medical records to assign accurate ICD-10-CM, ICD-10-PCS, and DRGs. Data Validation: Perform 100% data validation of assigned encounters to ensure diagnostic integrity. Provider Queries: Interface with clinicians for...

Inpatient Coder (Remote) Full-time Work From Home Must have CCS, RHIA, or RHIT certification Job Summary As a Coding Integrity Specialist III WORK FROM HOME, you will review and evaluate hospital inpatient medical record documentation to assign, sequence, edit and/or validate the appropriate ICD-10-CM and ICD-10-PCS codes. A CIS III performs coding and/or code/DRG validation across multiple entities by applying all appropriate coding guidelines and criteria for code selections. Job Qualifications Assign, sequence, validate, and/or edit codes/DRGs and abstracted data (e.g., physician, discharge disposition, query tracking) for inpatient records for multiple facilities using ICD-10-CM and ICD-10-PCS Maintain or exceed established accuracy standards Maintain or exceed established productivity standards Utilize the complete patient medical record documentation in code/DRG assignment, validation, and/or editing of codes/DRGs Undergraduate (Associate's or Bachelor's)...

Job Title Location: Miramar, Florida At Memorial, we are dedicated to improving the health, well-being and, most of all, quality of life for the people entrusted to our care. An unwavering commitment to our service vision is what makes the difference. It is the foundation of The Memorial Experience. Job Description Utilizing an electronic medical record and computerized encoder, assigns and sequences diagnosis and procedure codes and present on admission indicators for inpatient encounters based on medical record documentation in accordance with Official Coding Guidelines, CMS regulations, encoder software guidance and Health Information Management (HIM) policies and procedures. Responsibilities Maintains strict adherence to patient confidentiality according to MHS Standards and regulatory requirements. Formulates physician queries for validation of pathological findings. Requests clinical validation queries for Clinical Documentation Integrity (CDI) review and follow-up....

Health Information Management Coder Location: Miramar, Florida At Memorial, we are dedicated to improving the health, well-being and, most of all, quality of life for the people entrusted to our care. An unwavering commitment to our service vision is what makes the difference. It is the foundation of The Memorial Experience. Summary Utilizing an electronic medical record and computerized encoder, assigns and sequences diagnosis and procedure codes and present on admission indicators for inpatient encounters based on medical record documentation in accordance with Official Coding Guidelines, CMS regulations, encoder software guidance and Health Information Management (HIM) policies and procedures. Responsibilities Reviews and validates accuracy of Admission-Discharge-Transfer (ADT) data fields; abstracts discharge disposition, physicians, procedure dates, and present on admission (POA) indicators. Maintains strict adherence to patient confidentiality according to MHS...

Apolis is seeking an experienced Inpatient Coder with strong AHIMA credentials and extensive inpatient coding experience in Academic/Trauma Level 1 facilities. The ideal candidate will accurately assign ICD codes, ensure coding compliance, and maintain high productivity and quality standards. This remote contract role requires reviewing documentation, querying physicians when needed, using electronic encoders, and performing coding audits to uphold 98% accuracy while meeting deadlines. #J-18808-Ljbffr

Job Description Job Description Description: At Sage Clinical RCM, you'll code high-acuity inpatient encounters across a national portfolio of health systems, from academic medical centers to community hospitals. No two client environments are identical, and that's the point. You'll sharpen your skills across specialties, payers, and documentation styles instead of coding the same census for years. What You'll Do Review inpatient encounters and assign accurate ICD-10-CM/PCS codes and DRGs that hold up to audit. Read documentation critically. When it doesn't support the coded services, flag it and escalate the gap. Code in full compliance with CMS requirements, payer-specific rules, and official coding guidelines. Move confidently between client workflows, systems, and audit expectations. Hold the line on quality (95% accuracy or better) while meeting realistic productivity standards. Requirements: What You Bring Active RHIA, RHIT, and/or CCS credential....

Job Description Job Description Description: CPC-As are not being considered at this time. We're coding rebels with a cause. KODE is a health-tech company developed by medical coders for medical coders looking to change the way things are done in the industry. Our company may be young but we're growing rapidly. That also means we're not buried in outdated policies and bureaucracies.Coders play a critical role in healthcare, but have you ever felt like you're just a cog in the machine? At KODE there are no cogs, there are people. We aren't looking for a coder to fill an open position simply. We're looking for a new teammate passionate about professional coding who wants to join our collective mission to be awesome.We're serious about two things: coding and treating you like the professional you are. If this intrigues you, please keep reading. About this Role We're looking for a Facility Inpatient Coder to join our company! Responsibilities: Review medical records...

Job Description Job Description Job Title: Specialty Inpatient Coder Location: Remote Shift (EST): MondayFriday or SundayThursday; 1st or 2nd shift (flexible) Pay: $29+ (DOE) Essential Job Duties & Responsibilities: Review and code complex inpatient and outpatient records for high-priority service lines Assign accurate ICD-10-CM, ICD-10-PCS, and CPT codes based on physician documentation Focus on specialty areas including cardiovascular, transplant, orthopedic spine, invasive GI, and interventional radiology Use CAC systems (e.g., 3M CAC 360) and UHDDS guidelines for coding accuracy Abstract and enter clinical data into coding systems Ensure documentation supports all coded procedures and services Query providers to clarify incomplete or unclear documentation when needed Identify and correct coding and billing errors from audits and edits Monitor for medical necessity issues and potential non-covered services Maintain productivity, accuracy, and...

Job Description Job Description Description: About e4health At e4health, our vision is to Empower Better Health for our clients, our team, and the communities we serve. We live by five core values that guide everything we do: Embrace Change, Fun, and Learning: We maintain an unrelenting focus on quality, client success, and team member growth. Our PEOPLE Make the Difference: We build trusted relationships and celebrate wins every day. WE GROW: We believe in win/win outcomes—when our customers win, we win. GSD (Get Stuff Done): We say no to politics, drama, and egos, and yes to informed, agile decisions. Respectfully Listen, Challenge, & Support Each Other: We listen intently, challenge respectfully, and support fully. Serving more than 400 hospitals and health systems nationwide for nearly two decades, e4health provides solutions to tackle the toughest problems in healthcare with unmatched technology, mid-revenue cycle, and operational expertise. Our...

The Medical Records Coder II will improve documentation, data quality and revenue cycle operations. The coder assigns International Classification of Disease system-10 (ICD), CM, and PCS codes according to AHA – AMA Guidelines, CMS and NGS. Core Job Responsibilities Assign diagnosis and procedure codes, for accurate and timely billing of most appropriate payer Audit charges and establish proper coding in collaboration with providers Initiate and follow up on queries with providers Assist departments with diagnostic and procedural coding Respond to Insurance, compliance and RAC denials Review and assist in the maintenance of coding related policies and procedures Performs other duties as required. Education/Experience Requirements REQUIRED: AS in Health Information Management, a related degree or equivalent experience 1 year of experience as an inpatient coder. Knowledge of EMR, Coding Software, and Microsoft Office Knowledge/understanding of modifiers, medical...

Datavant is the data collaboration platform trusted for healthcare. Guided by our mission to make the world’s health data secure, accessible and actionable, we provide critical data solutions for organizations across the healthcare ecosystem - including providers, health plans, researchers, and life sciences companies. From fulfilling a single patient’s request for their medical records to powering the AI revolution in healthcare, Datavanters are building the future of how data is connected and used to improve health. By joining Datavant today, you’re stepping onto a driven and highly collaborative team that is passionate about creating transformative change in healthcare. What We’re Looking For We’re looking for experienced and credentialed inpatient coders to become an integral part of our team. The ideal candidate for this role possesses high attention to detail and a depth of knowledge in medical terminology. This role is fully remote with a flexible schedule, allowing you to...

Get started on an exciting career in health information management. We’re with you every step of the way. Starts out onsite, then transitions to REMOTE 4 days/week. Job Summary: Required Services provide single path medical coding services and related medical records functions. Single path coding combines facility coding and professional coding and allows one coder to code facility and professional codes for the same patient utilizing a single coding platform. perform technically complex professional services coding for medical conditions and assign the correct International Classification of Diseases, ICD-10-CM, Procedure Coding System (PCS) Current Procedural Terminology (CPT), Health Care Financing Administration Common Procedure Coding System (HCPCS), and Evaluation and Management (E&M) codes for diagnosis, acuity of care and procedures for a wide range of medical specialties to include coding of complicated cases identified as difficult to classify such as treatment of...

Summary Outpatient/Inpatient (Coder) select codes from current versions of ICD CM, PCS classification systems for inpatient facility and/or professional services. Inpatient duties consist of the performance and review of documentation within the health record to assign ICD codes for diagnosis, complications/major complications, comorbid/major comorbid conditions, surgery, and procedures for assignment of diagnosis related groups (DRG),and/or assigning CPT/HCPCS codes. Responsibilities This job opportunity announcement (JOA) will be used to fill 1 full-time and permanent Medical Records Technician (Outpatient/Inpatient Coder) vacancy(s) at the Memphis, TN Veteran Affairs Medical Center (VAMC), with Business Office Service. The technician is assigned to the Health Information Management Section (HIMS), coding/analysis unit, VAMC Memphis, TN. Outpatient/Inpatient MRTs(Coder) select and assign codes from current versions of ICD CM, PCS, and/or CPT and HCPCS classification systems for...

At UK St.Claire, our staff is our greatest asset in the mission to create a healthier and more prosperous population. We strive to foster the talent and potential of our employees and prioritize safe working conditions and equal compensation rates to ensure that continual growth is possible. Job Summary Responsible for performing complex inpatient coding and ensuring accuracy, compliance, and timeliness in hospital billing. Provides advanced expertise in ICD-10-CM, ICD-10-PCS coding, and DRG assignment to optimize reimbursement and reduce denials. Ensures coding accuracy by reviewing high‑complexity cases and participating in audits. Coordinates with providers, CDI specialists, and revenue cycle staff to improve documentation and coding quality. Essential Functions Performs comprehensive analysis of inpatient clinical documentation to accurately assign ICD-10-CM and ICD-10-PCS codes in compliance with Office Coding Guidelines. Codes a wide range of inpatient cases from moderately...

Full-time Company Description Accounting and Finance/Healthcare Job Description Specialist-Concurrent Coding/Inpatient Scottsdale Arizona 85258 Exp 2-5 Degree Associates Job Summary: The Concurrent Coding Specialist performs and facilitates concurrent inpatient coding in order to establish a working DRG. Ensures high quality documentation that is thorough, accurate and complete to ensure accurate reimbursement capture. He or she will concurrently reviews health records, identifies key clinical data elements within the record, and translate this data from verbal description of disease, injuries and procedures into numerical designations, applying ICD coding systems. Audits for documentation opportunities and queries clinical staff with CDI to fill in any gaps, clarify confusing, incomplete or conflicting information and obtain any needed additional documentation in real time. Ensures coding compliance and acts as technical resource, resolves issues, educates and works closely...

Summary Join a leading healthcare organization as an Inpatient Health Information Coding Specialist, where you\'ll play a vital role in ensuring the accuracy, integrity, and quality of clinical data. This opportunity is ideal for experienced inpatient coders who enjoy working with challenging medical cases, collaborating with clinical teams, and contributing to both financial and patient care outcomes. You\'ll have the chance to work within a complex healthcare environment that values professional expertise, continuous learning, and coding excellence. About the Opportunity This position offers the opportunity to work with a highly skilled healthcare team supporting a large, sophisticated hospital environment. You\'ll be involved in coding some of the most medically complex patient encounters, helping ensure accurate reimbursement, regulatory compliance, and quality reporting. Success in this role comes from combining strong coding expertise with sound clinical judgment, attention...

Facility Inpatient Coder We're coding rebels with a cause. KODE is a health-tech company developed by medical coders for medical coders looking to change the way things are done in the industry. Our company may be young but we're growing rapidly. That also means we're not buried in outdated policies and bureaucracies. Coders play a critical role in healthcare, but have you ever felt like you're just a cog in the machine? At KODE there are no cogs, there are people. We aren't looking for a coder to fill an open position simply. We're looking for a new teammate passionate about professional coding who wants to join our collective mission to be awesome. We're serious about two things: coding and treating you like the professional you are. If this intrigues you, please keep reading. Responsibilities: Review medical records to assign appropriate ICD-10, CPT, HCPCS codes accurately Review physician documentation and perform audits to determine accuracy as needed Meet and exceed...

Inpatient Coding Specialist Under direct supervision, accurately codes hospital inpatient accounts for the purpose of appropriate reimbursement, research, statistics and compliance to federal and state regulations in accordance with established ICD-10-CM/PCS coding classification systems. The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified. 1. Serves as a clinical coding subject matter expert, and utilizes critical thinking to analyze and evaluate documentation issues with consultation from the medical and clinical staff, and clinical documentation specialists as needed. a. Analyzes, codes and abstracts complex inpatient cases such as trauma, rehab, neurology, critical care, etc. utilizing the ICD-10-CM and ICD-10-PCS nomenclature to ensure accurate APR-DRG/SOI/ROM and POA assignment....

Location: Miramar, Florida At Memorial, we are dedicated to improving the health, well-being and, most of all, quality of life for the people entrusted to our care. An unwavering commitment to our service vision is what makes the difference. It is the foundation of The Memorial Experience. Summary: Utilizing an electronic medical record and computerized encoder, assigns and sequences diagnosis and procedure codes and present on admission indicators for inpatient encounters based on medical record documentation in accordance with Official Coding Guidelines, CMS regulations, encoder software guidance and Health Information Management (HIM) policies and procedures. Responsibilities: Reviews and validates accuracy of Admission-Discharge-Transfer (ADT) data fields; abstracts discharge disposition, physicians, procedure dates, and present on admission (POA) indicators.Maintains strict adherence to patient confidentiality according to MHS Standards and regulatory requirements.Reviews...