Medical Coder Evaluation & Management (E&M)

We are seeking a certified and experienced Medical Coder with a specialization in Evaluation & Management (E&M). This role is fundamental to the revenue cycle, requiring an individual to accurately code patient evaluations and management services while ensuring strict compliance with all coding guidelines and regulations. The ideal candidate will possess deep E&M expertise, a meticulous attention to detail, and a collaborative approach to working with healthcare professionals.

Key Responsibilities:

• Analyze medical records and documentation to accurately identify services provided during patient evaluations and management encounters.
• Assign appropriate E&M codes based on the level of service, adhering to coding guidelines and regulations such as CPT, ICD-10-CM, and HCPCS.
• Ensure coding accuracy and compliance with all coding standards, including documentation requirements for various E&M levels.
• Stay current with all relevant coding guidelines and updates from regulatory bodies, including the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association (AMA).
• Adhere to coding regulations such as HIPAA to ensure patient privacy and confidentiality.
• Collaborate with healthcare professionals, including physicians and nurses, to obtain necessary information and address coding-related queries.
• Work closely with billing and revenue cycle teams to ensure accurate claims submission and timely reimbursement.
• Conduct regular audits and quality checks on coded medical records to identify errors or opportunities for improvement.
• Participate in coding compliance programs and initiatives to maintain high accuracy and quality standards.

Job Requirements:

• A Certified Professional Coder (CPC) or an equivalent coding certification (CCS-P, CRC) is mandatory.
• In-depth knowledge of Evaluation & Management coding guidelines and principles is required.
• Proficiency in using coding software and Electronic Health Record (EHR) systems.
• Strong familiarity with medical terminology, anatomy, and physiology.
• Exceptional attention to detail and analytical skills.
• Excellent communication and interpersonal skills to effectively collaborate with providers and staff.
• A strong compliance-oriented mindset and understanding of healthcare regulations.
• The ability to work both independently and as part of a team.
• Strong organizational and time management abilities, with a continuous learning mindset.