Coder 2 - Health Information Management - Full… at Concord… · Concord

Summary

Responsible for reviewing demographic and clinical medical records, assigns appropriate ICD-10-CM/PCS and CPT/HCPC codes based on provider documentation and current coding guidelines. Enters this information into the electronic system for the purpose of maintaining a complete and accurate clinical data base. Works across multiple encounter types, including Observation/Outpatient in a Bed, Emergency Department, Urgent Care, Ambulatory Surgery, and Ancillary. 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.

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 of 1 year coding experience in a health care setting.

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.

Concord Hospital is an Equal Employment Opportunity employer. It is our policy to provide equal opportunity to all employees and applicants and to prohibit any discrimination because of race, color, religion, sex, sexual orientation, gender, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status.

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If you are an individual with a disability and require a reasonable accommodation to complete any part of the application process, you may contact Human Resources at 603-230-7269.

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 quickly and master complex coding scenarios often encountered in academic or multispecialty healthcare settings.
• Familiarity with outpatient reimbursement methodologies, including the Outpatient Prospective Payment System (OPPS) and associated regulations.
• Comfortable using modern coding tools, such as encoder software, AI-assisted coding platforms, and coding reference applications.
• Skilled in written and verbal communication, with the ability to collaborate across teams in a virtual, hybrid, or remote environment.
• Highly organized and detail-oriented, with strong critical thinking and analytical abilities for interpreting provider documentation accurately.
• Proficient in Microsoft Office tools like Outlook, Word, and Excel, particularly for documentation, data tracking, and team collaboration.
• Able to work independently with minimal supervision, maintaining high performance and productivity standards in a remote setting.
• Willing to work flexible hours, including weekends or evenings if needed, to support business needs and workflow turnaround times.

Physical and Work Requirements

The physical demands and characteristics of the remote or hybrid work environment described here are representative of those that may be encountered by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform these functions.

This position is classified as SEDENTARY per the Dictionary of Occupational Titles. It primarily involves prolonged periods of sitting while using a computer and engaging in virtual communication platforms. The employee may occasionally be required to lift or carry items weighing up to 10 pounds, such as reference materials or office equipment.

While performing the duties of this job, the employee is regularly required to:

• Sit at a desk or workstation for extended periods.
• Perform repetitive tasks involving keyboarding and data entry.
• Use auditory and visual perception to interpret documentation, communicate via headset or video calls, and navigate electronic systems.

Occasional physical movements may include reaching, bending, or standing briefly. Specific vision abilities required include close vision, peripheral vision, depth perception, and the ability to adjust focus to digital screens.

The noise level in a remote setting is typically quiet. Employees are expected to provide a work environment conducive to focused, uninterrupted tasks, with minimal background distractions when participating in meetings or collaborative virtual sessions.