Employment Type: Full-time
Shift: Day Shift

Job Summary:
This role involves reviewing physician or provider documentation from Emergency Department (ED) and Outpatient Observation records—whether electronic, paper, or hybrid—to identify and assign principal and secondary diagnoses and procedures. The position may also include assigning ER and Observation charges and calculating Observation hours if required.

Key Responsibilities:

– Use encoder software and online tools to assign ICD-CM, ICD-PCS, CPT, and HCPCS codes, including necessary modifiers.
– Follow coding guidelines from CMS, AHA, AMA, AHIMA, and internal policies.
– Apply Trinity Health’s Mission, Vision, and Values in daily work.
– Navigate patient records and systems to determine diagnoses, procedures, and appropriate codes.
– Assign charges and calculate Observation hours based on documentation, where applicable.
– Use compliant query practices to clarify documentation with physicians or other healthcare providers.
– Communicate with clinical staff and case management to resolve documentation issues.
– Collaborate with HIM and Patient Business Services to address billing, claims, and reimbursement issues.
– Identify and report ethical concerns related to documentation or coding.
– Track missing documentation and follow up on outpatient queries.
– Stay current with outpatient coding and reimbursement updates.
– Meet or exceed quality and productivity standards.
– Maintain required continuing education units (CEUs).
– Perform additional duties as assigned.
– Adhere to all applicable laws, regulations, and Trinity Health policies.

Minimum Requirements:

– Completion of an AHIMA- or AAPC-approved coding program, or an associate degree in Health Information Technology or related field. A bachelor’s degree in Health Information Management or related field is preferred.
– Must hold one of the following certifications: CCA, CPC, COC, RHIT, RHIA, or CCS.
– At least two years of recent experience in coding for emergency department and observation or physician services.
– Experience with encoder/grouping software or computer-assisted coding (CAC) preferred.
– Proficiency with standard computer applications and web-based tools.
– Strong verbal and written communication skills; ability to work independently and exercise sound judgment.
– Strong analytical, critical thinking, and problem-solving skills.
– Excellent organizational and customer service abilities.
– Must be adaptable and able to manage multiple priorities.
– Comfortable working in a fully virtual, collaborative environment with minimal supervision.
– Must demonstrate integrity, honesty, and a commitment to Trinity Health’s mission and values.

Physical and Work Environment Requirements:

– Must be able to manage shifting priorities and work on multiple tasks in potentially high-stress environments.
– Must follow Trinity Health policies and procedures.
– Requires extensive computer use.
– Must be able to work with frequent interruptions and perform detailed tasks.
– May involve sitting for extended periods.
– Must be able to travel to Trinity Health locations as needed.
– If working remotely, must comply with Trinity Health’s remote work policies.

Hourly Pay Range: $24.05 – $36.08

Note: This job description outlines general responsibilities and is not an exhaustive list of duties.

Our Commitment:
We are dedicated to honoring each person’s dignity and celebrating diverse experiences and perspectives. We are an Equal Opportunity Employer and welcome all qualified applicants, regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other protected characteristics.