Hospital Outpatient Coder

About This Role

The Hospital Outpatient Coder is responsible for the accurate coding and abstracting of diagnoses, conditions, and procedures from medical record documentation for various hospital outpatient services. This role ensures all coding is performed in accordance with regulatory requirements and Kaiser Permanente's guidelines.

Responsibilities

• Review medical record documentation to identify diagnoses and procedures for coding.
• Independently organize and prioritize work assignments to ensure timely and compliant coding.
• Code diagnoses and procedures using ICD-CM, CPT, and HCSPCS classification systems.
• Sequence diagnoses and procedure codes according to official guidelines and regulations.
• Verify and abstract appropriate data for submission and reporting, correcting as needed.
• Ensure accuracy and integrity of abstracted and coded data consistent with medical record documentation.
• Interact with physicians to clarify and accurately document patient information.
• Maintain confidentiality and security of patient records and systems.
• Meet established coding/abstracting productivity and quality standards.

Requirements

• Achieve a minimum score of 75% on the Hospital Outpatient Coder test.
• Basic knowledge and use of computer keyboard and mouse.
• Ability to meet productivity and quality standards.
• Demonstrated ability to understand clinical content of health records and translate into appropriate codes.
• Demonstrated knowledge of anatomy, physiology, medical terminology, and disease process.
• Demonstrated knowledge of coding and sequencing guidelines (ICD-CM, CPT, Medicare).
• Basic knowledge of reimbursement methodologies and coding classifications.
• Maintain coding credential and complete required Continuing Education (CE) units.
• Abide by the AHIMA and/or AAPC code of ethics.
• Willingness to work in a Labor Management Partnership environment.

Qualifications

• High School Diploma or GED and demonstrated completion of classes in medical terminology, anatomy, physiology, current ICD-CM and CPT coding conventions and disease process from an accredited program.
• Two years of continuous hospital coding/abstracting experience within the last five years.

Skills

* Required skills

Certifications