Clinical Documentation Integrity Coder - Remote

Overview

The Clinical Documentation Integrity (CDI) Coder is responsible for conducting comprehensive reviews of medical records to ensure the accurate assignment of diagnostic and procedural codes in alignment with provider documentation. This role is critical to maintaining compliance with organizational policies, ICD-10-CM, CPT, and HCPCS guidelines, as well as CMS regulations.

In Short

• Conduct detailed reviews of medical records to accurately assign ICD-10-CM, CPT, and HCPCS codes ensuring compliance with coding guidelines and payer-specific regulations.
• Identify and report documentation deficiencies or discrepancies impacting coding accuracy.
• Collaborate with the Clinical Documentation Integrity (CDI) team to address gaps and improve documentation quality.
• Maintain up-to-date knowledge of coding guidelines, updates, and payer-specific requirements.
• Support compliance initiatives by identifying trends, patterns, and areas requiring improvement where applicable.
• Contribute to audits and coding quality assurance processes.

Requirements

• Current certification as a Certified Professional Coder (CPC), Certified Coding Specialist – Physician-based (CCS-P), or Certified Risk Adjustment Coder (CRC).
• Bachelor’s degree in a healthcare-related field or equivalent experience preferred.
• 2+ years of experience in medical coding, preferably in risk adjustment or outpatient settings.
• Thorough understanding of ICD-10-CM, CPT, and HCPCS coding guidelines and CMS regulations.
• Experience with coding for value-based care models and risk adjustment programs.
• Strong attention to detail and the ability to work independently in a production-oriented environment.
• Proficient with coding software and electronic medical record (EMR) systems.

Benefits

• Certification in Clinical Documentation Integrity (e.g., CDEO®, CCDS-O) preferred.
• Experience working in a value-based care organization, health insurance companies, or Accountable Care Organization (ACO) preferred.
• Familiarity with Google Suite tools or similar platforms preferred.
• Prolonged periods of sitting and extensive use of a computer.
• Ability to meet deadlines and maintain high levels of focus in a remote work environment.