863 clinical documentation improvement jobs found

## Clinical Documentation Improvement Nurse Coder (Certified)Applylocations: Portland, MEtime type: Full timeposted on: Posted 2 Days Agojob requisition id: REQ-2026-227Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.## Position SummaryThe Clinical Documentation Improvement (CDI) Nurse Coder supports accurate and complete clinical documentation that reflects the severity of illness, quality...

Careers With Purpose Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America's heartland. Facility: Remote SD (Central Time) Location: Remote, SD Address: Shift: 8 Hours - Day Shifts Job Schedule: Full time Weekly Hours: 40.00 Salary Range: $22.50 - $36.00 Job Summary Reviews inpatient clinical documentation, procedural information, and diagnostic results to apply ICD-10-CM and PCS diagnostic and procedural codes used for billing, internal and external data reporting, research, regulatory compliance, and quality monitoring. Using professional coding training, critical thinking, and clinical acumen, accurately assigns ICD-10-CM and ICD-10-PCS codes to conditions and procedures documented within the inpatient electronic medical record. Applies Official Coding Guidelines, CMS regulations/guidelines, and other coding...

Summary: Selected by CHRISTUS Health Coding Leadership, to focus coding skills and expertise on designated Inpatient or Outpatient high dollar or specialty account types. Specialty Coder is responsible for maintaining current and high-quality ICD-10-CM, ICD-10-PCS and/or CPT coding for the Inpatient and or/ Outpatient diagnoses and procedural occurrences, through the review of clinical documentation and diagnostic results, with a consistent coding accuracy rate of 95% or better. Specialty Coder will accurately abstract data into any and all appropriate CHRISTUS Health electronic medical record systems, verifying accurate patient dispositions and physician data, following the Official ICD-10-CM and ICD-10-PCS Guidelines for Coding and Reporting and AMA CPT Guidelines. Coder will work collaboratively with various CHRISTUS Health departments, including but not limited to the HIM and Clinical Documentation Specialists, to ensure accurate and complete physician documentation to support...

Overview Lakeland Regional Health is a leading medical center located in Central Florida. With a legacy spanning over a century, we have been dedicated to serving our community with excellence in healthcare. As the only Level 2 Trauma center for Polk, Highlands, and Hardee counties, and the second busiest Emergency Department in the US, we are committed to providing high-quality care to our diverse patient population. Our facility is licensed for 892 beds and handles over 200,000 emergency room visits annually, along with 49,000 inpatient admissions, 21,000 surgical cases, 4,000 births, and 101,000 outpatient visits. Lakeland Regional Health is currently seeking motivated individuals to join our team in various entry-level positions. Whether you're starting your career in healthcare or seeking new opportunities to make a difference, we have roles available across our primary and specialty clinics, urgent care centers, and upcoming standalone Emergency Department. With over 7,000...

This is a remote role We are seeking a highly motivated and dedicated coding professional to join our team as an contract inpatient facility coder. This position is remote. The ideal candidate must have at least 5 years of coding experience with facility inpatient services. The position requires one to be resourceful, organized, independent, and extremely driven. The ideal candidate will possess the following: Minimum 5 years of coding experience Extensive coding in all aspects of inpatient coding High level of proficiency in anatomy, physiology, disease process, and pharmacology Excellent written and verbal communication skills Detail oriented and deadline driven attitude Sound knowledge of medical terminology Strong computer skills (Excel, Word, and internet) Ability to think critically Ability to multitask and keep a sense of urgency Excellent customer service skills Strong time management, organization skills, and work ethic Job Duties: Accurately code medical...

Supervisory Medical Records Technician (Coder) develops performance standards and conducts performance evaluations for subordinate staff. Interviews new employees, recommends selection, and carries out training and development of reassignments, awards or disciplinary action. Approves leave schedules. Implements provisions of EEO programs to ensure fair and equal treatment for all employees. Keeps employees informed of management goals and objectives. Citizenship. Citizen of the United States. Experience and Education (1) Experience. One year of creditable experience that indicates knowledge of medical terminology, anatomy, physiology, pathophysiology, medical coding, and the structure and format of a health records. OR, (2) Education. An associate's degree from an accredited college or university recognized by the U.S. Department of Education with a major field of study in health information technology/health information management, or a related degree with a minimum of 12...

PYA is seeking an Inpatient/Outpatient Facility Coding Auditor to join its high-performing and privately-owned firm with a dynamic culture and a strong national reputation. This individual will support PYA's Revenue and Compliance Advisory Program . RESPONSIBILITIES : Apply inpatient and outpatient facility/hospital coding and reimbursement methodologies to provide advisory services to PYA clients with a focus on the following: ICD-10-CM and PCS/CPT/HCPCS code assignment MS-DRG and other DRG validation APC validation and charge capture Clinical documentation improvement Regulatory compliance for third party payors Work in collaboration with the PYA executive team and other service lines to offer complete business solutions to clients Manage the preparation of excellent client deliverables and exhibit exceptional project management skills while balancing firm risk and compliance with appropriate professional standards QUALIFICATIONS : Professional...

Coding Specialist Responsible for coding inpatient or outpatient records, reviews documentation and properly identifies and assigns ICD-10-CM, CPT-4/HCPCS and/or ICD-10-PCS codes for all reportable diagnoses and procedures. This includes determining the correct principal diagnosis, co-morbidities, and complications, secondary conditions, and surgical procedures. Essential Functions and Responsibilities As Assigned : Responsible for outpatient coding and charge validation (charge entry) Responsible for coding simple inpatient visits (with < 30 days of LOS) Properly identifies and assigns ICD-10-CM, CPT-4 or ICD-10- PCS codes. Determines the correct principal diagnosis, co-morbidities, and complications, secondary conditions, and surgical procedures. Ensures codes are assigned correctly and sequenced appropriately in compliance with medical coding guidelines and policies. Maintains knowledge of current coding guidelines by self-study, assigned education,...

This position is located in the Health Information Management (HIM) section at the Durham VA Medical Center. MRTs (Coder-Inpatient) are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. Basic Requirements United States Citizenship: Non-citizens may only be appointed when it is not possible to recruit qualified citizens in accordance with VA Policy. One year of creditable experience equivalent to the next lower grade level. Demonstrated KSAs. In addition to the experience above, the employee must demonstrate all of the following KSAs: Ability to analyze the health record to identify all pertinent diagnoses and procedures for inpatient coding and to evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the health record, the terminology, the significance of the...

Job Title Hospital Inpatient Coder III Job Description The Hospital Inpatient Coder III uses clinical coding knowledge based on the Official Coding Conventions guidelines and AHA Coding Clinic, to assign ICD-9 and/or ICD-10 codes to the highest level of accuracy for each inpatient encounter. Works closely with physicians, clinical documentation improvement specialist, quality, and patient finance staff. Plays a key role in billing, research, internal and external reporting, and regulatory compliance. Ensures accuracy of DRGs and appropriate extraction of core data into HIM abstracting system to data warehouse repository. Facilitates accurate data for patient acuity, severity of illness, and quality outcomes. Minimum Qualifications High School diploma or equivalent. 5 years inpatient and outpatient coding experience in an acute care environment. Must complete coding proficiency evaluation. Extensive knowledge and understanding of MS-DRGs, disease process, clinical...

Certified Medical Records Coder Position The County of Riverside - Riverside University Health System - Medical Records Department is seeking to fill a Certified Medical Records Coder position located in Riverside. Under general supervision, performs advanced coding and abstracting of inpatient medical record entries according to the most current edition of International Classification of Diseases - Clinical Modification System (ICD-CM), Procedure Coding System (PCS) and Current Procedural Terminology (CPT); performs other related duties as required. The Certified Medical Records Coder - Inpatient classification performs the most complex coding and abstracting of a high volume of patient records in the Medical Records Department and reports to an appropriate supervisory or manager level position. The Certified Medical Records Coder - Inpatient is distinguished from the Certified Medical Records Coder - Outpatient in that the latter does not require an extensive knowledge of...

Risk Adjustment Coder II The Risk Adjustment Coder II provides advanced support for complex medical record reviews to ensure the correct capture of chronic conditions and complexities to calculate a patient's risk score, by mapping diagnoses to Hierarchical Condition Categories (HCCs) while adhering to CMS guidelines and internal coding policies for the following programs: including, but not limited to, Commercial Risk Adjustment, Medicare Risk Adjustment, and HHS and Medicare RADV (Risk Adjustment Data Validation). The Risk Adjustment Coder II will serve as a subject matter expert for risk adjustment and will assist in the development of team trainings, quality assurance audits, and collaborating with multiple departments across the organization. Job Specifications and Core Competencies: Provide advanced complex medical records reviews to identify and code all relevant diagnoses, including chronic conditions, utilizing ICD-10 coding guidelines for Commercial and Medicare risk...

Senior Specialty Physician Coder Interventional Our client, a healthcare company, is looking for a Senior Specialty Physician Coder Interventional for their Fountain Valley, CA location. Responsibilities: Achievement of productivity standards as established by management. Achievement of quality standards as established by management. In adherence with standard work, analyze and interpret medical information in the medical record and assign and sequence the correct ICD-10-CM, CPT, and/or HCPCS codes to the diagnoses/procedures of office, inpatient and/or outpatient medical records according to established coding guidelines, including the ability to review and natively code surgical operative and/or procedure reports. In adherence with standard work, follow established workflow for working claim denials in the Follow-Up work queues and identify opportunities for billing/coding improvements. Participate in developing, implementing, and reviewing programs for coding compliance...

Summary MRTs are skilled in classifying medical data from patient health records in the hospital setting, and/or physician-based settings, such as physician offices, group practices, multi-specialty clinics, and specialty centers. These coding practitioners analyze and abstract patients. health records and assign alphanumeric codes for each diagnosis and procedure. Learn more about this agency Duties Help ** *THIS IS AN ON SITE POSITION, YOU MUST LIVE WITHIN OR BE WILLING TO RELOCATE WITHIN A COMMUTABLE DISTANCE OF THE DUTY LOCATION*** Duties of the Medical Records Technician (Coder) In/Outpatient include, but not limited to: Assigns codes to documented patient care encounters (outpatient and/or inpatient professional services) covering the full range of health care services provided by the VAMC. Selects and assigns codes from the current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), and/or Healthcare...

Risk Adjustment Coding Auditor (Remote) *Location:* 100% Remote (Approved U.S. States Only) *Employment Type:* Contract (5 Months) *Schedule:* First Shift Overview We are seeking experienced Risk Adjustment Coding Auditors to support a growing healthcare organization during a high-volume operational period. This role is ideal for professionals with deep expertise in HCC coding, risk adjustment auditing, and regulatory compliance who thrive in a production-driven environment. This position offers the opportunity to work remotely while contributing to the accuracy, integrity, and compliance of risk adjustment programs that support quality healthcare outcomes and reimbursement processes. Key Responsibilities * Audit risk adjustment codes for accuracy, consistency, and compliance with coding guidelines and best practices * Perform retrospective and prospective medical record reviews * Validate diagnosis coding based on provider documentation and CMS-HCC requirements * Identify...

Risk Adjustment Coding Auditor (Remote) Location: 100% Remote (Approved U.S. States Only) Employment Type: Contract (5 Months) Schedule: First Shift Overview We are seeking experienced Risk Adjustment Coding Auditors to support a growing healthcare organization during a high-volume operational period. This role is ideal for professionals with deep expertise in HCC coding, risk adjustment auditing, and regulatory compliance who thrive in a production-driven environment. This position offers the opportunity to work remotely while contributing to the accuracy, integrity, and compliance of risk adjustment programs that support quality healthcare outcomes and reimbursement processes. Key Responsibilities Audit risk adjustment codes for accuracy, consistency, and compliance with coding guidelines and best practices Perform retrospective and prospective medical record reviews Validate diagnosis coding based on provider documentation and CMS-HCC requirements Identify coding...

Coding Specialist Sanford Health, the largest rural health system in the United States, is dedicated to transforming the health care experience and providing access to world-class health care in America's heartland. Facility: Remote SD (Central Time) Location: Remote, SD Shift: 8 Hours - Day Shifts Job Schedule: Full time Weekly Hours: 40.00 Salary Range: $22.50 - $36.00 Job Summary: Reviews inpatient clinical documentation, procedural information, and diagnostic results to apply ICD-10-CM and PCS diagnostic and procedural codes used for billing, internal and external data reporting, research, regulatory compliance, and quality monitoring. Using professional coding training, critical thinking, and clinical acumen, accurately assigns ICD-10-CM and ICD-10-PCS codes to conditions and procedures documented within the inpatient electronic medical record. Applies Official Coding Guidelines, CMS regulations/guidelines, and other coding standards and guidelines established for use with the...

Job Description Job Description PYA is seeking an Inpatient/Outpatient Facility Coding Auditor to join its high-performing and privately-owned firm with a dynamic culture and a strong national reputation. This individual will support PYA’s Revenue and Compliance Advisory Program . RESPONSIBILITIES : Apply inpatient and outpatient facility/hospital coding and reimbursement methodologies to provide advisory services to PYA clients with a focus on the following: ICD-10-CM and PCS/CPT/HCPCS code assignment MS-DRG and other DRG validation APC validation and charge capture Clinical documentation improvement Regulatory compliance for third party payors Work in collaboration with the PYA executive team and other service lines to offer complete business solutions to clients Manage the preparation of excellent client deliverables and exhibit exceptional project management skills while balancing firm risk and compliance with appropriate professional...

St. Tammany Health System seeks a Hospital Coder II to review and code complex hospital services, ensuring accurate ICD/CPT coding and DRG assignment. You will work with the Clinical Documentation Improvement team to maintain precise reimbursement and collaborate with management to meet deadlines. Successful candidates will have a CCS or 3–6 years inpatient coding experience, strong ICD-10 knowledge, and excellent communication skills. #J-18808-Ljbffr

Medical Coder The Medical Coder is responsible for ICD-10 coding of diagnoses and procedures of inpatient/outpatient discharged patient records. Job Specific Responsibilities Daily assignments may include but are not limited to: Apply diagnoses codes to in-patient, out-patient, and emergency services Maintain knowledge of current laws and regulations related to insurance, Medicare, Medicaid, and DRG coding, sequencing, and CPT coding Perform quality improvement reviews as assigned All other assigned duties related to Health Information Management Inpatient Coder Duties Review and analyze inpatient medical records to assign ICD-10-CM/PCS codes. Ensure completeness of the record to assign the accurate DRG (Diagnosis Related Group) assignment for reimbursement. Maintain knowledge of current coding guidelines, Coding Clinics and facility-specific coding policies. Collaborate with clinical documentation specialists as needed for unclear or inconsistent documentation...

Job Description Job Description PYA is seeking an Inpatient/Outpatient Facility Coding Auditor to join its high-performing and privately-owned firm with a dynamic culture and a strong national reputation. This individual will support PYA’s Revenue and Compliance Advisory Program . RESPONSIBILITIES : Apply inpatient and outpatient facility/hospital coding and reimbursement methodologies to provide advisory services to PYA clients with a focus on the following: ICD-10-CM and PCS/CPT/HCPCS code assignment MS-DRG and other DRG validation APC validation and charge capture Clinical documentation improvement Regulatory compliance for third party payors Work in collaboration with the PYA executive team and other service lines to offer complete business solutions to clients Manage the preparation of excellent client deliverables and exhibit exceptional project management skills while balancing firm risk and compliance with appropriate professional...

Facility: Mercy Hospital of Buffalo Shift: Shift 1 Status: Full Time FTE: 1.000000 Bargaining Unit: CWA Local 1133 Exempt from Overtime: Exempt: No Work Schedule: Days Hours: 7:00am-3:00pm Summary: Codes primarily acute hospital inpatient, SNF, Rehab, for the purpose of accurate reimbursement, research and compliance with federal regulations. Coding of Ambulatory, ER / Urgent Care, Interventional Radiology and same day surgery records is performed on an as needed basis. Diagnoses and procedures are coded through review of the entire medical record, utilizing International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) and Current Procedure Terminology (CPT) classifications. Queries physician for further clarification when there is uncertainty in the documentation of the medical record. Analyzes and reviews records for completeness. Actively participates as a member of the Clinical Documentation Improvement Team (CDI...

HIM Coder NeuroPsychiatric Hospitals is looking for a HIM Coder at our Huber Heights location. NPH is the national leader in providing medical and neurobehavioral care to patients in acute psychiatric distress. You will be joining a team of rock star staff who provide exceptional, patient-centered care and understand our patients are always our number one priority! Benefits of joining NPH as a HIM Coder Competitive pay rates Medical, Dental, and Vision Insurance NPH 401(k) plan with up to 4% Company match Employee Assistance Program (EAP) Programs Generous PTO and Time Off Policy Special tuition offers through Capella University Work/life balance with great professional growth opportunities Employee Discounts through LifeMart Responsibilities Codes inpatient medical records utilizing ICD-10-CM. Groups for MS-DRG assignment and optimization following coding guidelines. Assembles and analyzes medical records timely and accurately for quantitative deficiencies....

Summary Supervisory Medical Records Technician (Coder) develops performance standards and conducts performance evaluations for subordinate staff. Interviews new employees, recommends selection, and carries out training and development of reassignments, awards or disciplinary action. Approves leave schedules. Implements provisions of EEO programs to ensure fair and equal treatment for all employees. Keeps employees informed of management goals and objectives. Learn more about this agency Duties Help Total Rewards of a Allied Health Professional Duties include but are not limited to: Applies comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection. Selects and assigns codes from the current version of several coding systems to include...