Medical Coder (US Healthcare)

Position:

Job Summary:

Experienced Medical Coder responsible for accurate assignment of ICD-10-CM, CPT, and HCPCS codes across inpatient, outpatient, physician, home-health and hospice settings. The role requires deep familiarity with Medicare/Medicaid rules, payer policy nuances, and specialty coding (including PDGM/OASIS interplay for home health and hospice billing rules). Coders will partner closely with QA, clinical SMEs, and RCM operations to meet TAT and accuracy SLAs.

Core Responsibilities:

• Review clinical documentation (EHR notes, discharge summaries, OASIS, visit notes) and assign accurate ICD-10, CPT, and HCPCS codes.
• Ensure coding supports correct bill type (UB-04/837I vs. CMS-1500/837P) and revenue center entries for facility/hospice/home-health claims.
• Apply PDGM, OASIS and hospice payment rules when coding home health & hospice encounters; sequence diagnoses appropriately for terminal and supporting conditions. AAPCDecision Health Store
• Validate clinical documentation completeness; create provider clarification (CDI) queries where necessary.
• Identify denial-risk items and work with denial management/AR teams to reduce leakage.
• Post completed coded charts into the workflow and coordinate with QA for spot checks and rework.
• Meet daily/weekly throughput and accuracy SLAs; maintain documentation of coding rationale for audit trails.
• Participate in sprint-based workflows (time-boxed batches), daily standups and retrospectives to continuously improve throughput and accuracy.
• Contribute to internal coding guidance (cheat sheets), payer-specific rules library, and training for new hires.

Required Qualifications & Experience:

• Education:

  High school diploma; Associate degree in Health Information/related preferred. RHIT/RHIA may be preferred for senior roles. AHIMA+1

• Experience:

• Jr: 12 years medical coding (any US setting)
• Mid: 35 years coding experience, with some specialty exposure (home health/hospice preferred)
• Sr: 6+ years coding experience, plus leadership/mentorship or subject-matter ownership
• Strong working knowledge of ICD-10-CM, CPT, HCPCS, medical terminology, anatomy & physiology.
• Familiar with Medicare billing rules, payer edits, and claim formats (UB-04/1500/837).
• Comfortable working in an Agile/sprint environment and using digital Kanban/sprint boards.

Must-have Certifications (Recommended for Hiring/Shortlisting):

(Use these as minimum bar for mid/senior roles; Jr. roles may accept in-progress credentials.)

1. CPC (Certified Professional Coder)

   AAPC. Core outpatient/physician coding credential. AAPC

2. CCA / CCS / CCS-P

   AHIMA certifications for coding proficiency (CCA for foundational, CCS/CCS-P for advanced hospital/physician coding). AHIMA+1

3. CPB (Certified Professional Biller)

   AAPC (recommended if billing+coding combined).

KPIs / Performance Metrics to Measure Success:

• Turnaround time (TAT):

  avg hours from chart intake coded deliverable (target: 2448 hrs depending on SLA).

• First-pass accuracy:

  % codes accepted without rework (target: 95% for experienced coders).

• Throughput:

  charts coded per FTE per day.

• Denial leakage:

  % of coded charts where coding error led to claim denials.

• SLA compliance:

  % charts delivered within agreed SLA window.

• QA defect rate:

  number of coding defects per 100 charts.

• Sprint Commitment Fulfillment:

  % of sprint backlog completed (responsibility: Agile participation).