Role Description Responsible for primary diagnosis and procedural coding for designated ambulatory and hospital outpatient settings. Responsible for proficiently assigning proper and accurate medical codes for diagnosis, procedures, and services performed in an outpatient setting, such as, but not limited to emergency department, outpatient clinics, same day surgeries, or diagnostic testing (radiology and laboratory). Typically reports to the Coding Manager. Qualifications - High School Diploma or GED required; Associates degree in Health Information Management or any Healthcare Related Field preferred - Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or relevant Coding certification(s) from American Health Information Management Association (AHIMA) or American Association of Professional Coders (AAPC) required - Three (3) years of hospital or ambulatory coding experience required for Surgery/Observation - Two (2) years of hospital or ambulatory coding experience required for Emergency Department - Two (2) years of hospital or ambulatory coding experience required for Interventional Radiology - One (1) year of hospital or ambulatory coding experience preferred for Ancillary/Recurring - Experience coding in a level 1 trauma facility/academic teaching facility preferred - Effective oral and written communication skills - Strong knowledge of ICD-10-CM and/or CPT - Analytical skills necessary to interpret data contained in the health records and to assign appropriate codes - Proficient knowledge of human anatomy, physiology, medical terminology and surgical terminology - Critical thinking, good judgment and decision-making skills - Knowledge of coding compliance policies, official coding guidelines, regulatory requirements and internal policies and procedures affecting the coding process - Proficient in navigating a Windows-based application environment Requirements - Reviews medical record documentation to identify pertinent diagnosis/procedures that require code assignment for outpatient records and accurately code the diagnoses and procedures using ICD-10-CM coding conventions for the purpose of reimbursement, research, and compliance with federal regulations - Reviews the medical record to assure specificity of diagnoses, procedures, and appropriate reimbursement for hospital and professional charges - Queries physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes - Keeps abreast of coding guidelines and reimbursement reporting guidelines and brings identified concerns to manager for resolution - Effectively assigns ICD-10-CM, modifiers, and HCPCS codes to outpatient records - Responsible for maintaining 95% or greater ICD-10-CM and/or HCPCS coding and consistently meet established productivity standards while keeping abstracting errors to a minimum - Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines - Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service - Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff - Demonstrates commitment to caring for every member of our community by creating compassionate and personalized experiences. Models Memorial Hermann’s service standards by providing safe, caring, personalized and efficient experiences to patients and colleagues - Other duties as assigned

• Assigns appropriate codes to reflect all diagnoses and procedures from physician and nursing documentation during a patient encounter according to the most current coding methodologies. • Abstracts required data to input into the Medical Center's computerized database. • Converts all patient visits and encounters into appropriate DRG (Diagnosis-related group), ASC (Ambulatory Surgical Classification), APG (Ambulatory Patient Groups), APC (Medicare’s Ambulatory Patient Classification) assignments in order to optimize reimbursement for each patient encounter coded.

Role Description The Certified Coding Specialist II requires advanced knowledge of and skill in applying International Classification of Diseases and Procedures (ICD), and Current Procedural Terminology (CPT) code sets and associated Medicare/Medicaid rules and guidelines. - Reviews and interprets patient medical records documentation to identify pertinent diagnoses and procedures. - Assigns ICD-10-CM, ICD-10-CM and CPT 4 codes accurately and timely to the highest level of specificity based upon physician documentation for: - Ambulatory surgery - Special procedure - Observation - Emergency department - Outpatient ancillary - Clinic visit records - Primarily codes complex ambulatory surgery and a mixture of different types of Evaluation & Management medical records. - Assists with coding outpatient ancillary clinic, specialty clinic and emergency room record coding as necessary. - Communicates with physicians and other providers regarding documentation requirements. - Collaborates with different departments within CCHCS on patient cases regarding documentation needs and requirements, and coding assignment accuracy. - Maintains current knowledge of coding and documentation changes, rules and guidelines. Qualifications - High School Diploma. - Required: CCS or CPC with (1) year minimum current and continuous full-time ICD-10-CM & CPT-4 ambulatory surgery and evaluation & management coding. - Knowledge of medical terminology, anatomy and physiology and the disease process. - Ability to work well independently and productively with minimal guidance and supervision. - Detail-oriented, organized and flexible with exceptional interpersonal and communication skills. - Demonstrates coding skills and critical thinking skills utilizing current policies and procedures. - Demonstrated coding knowledge and proficiency is required through on-site evaluation prior to hire. - Preferred: RHIA, RHIT. - Knowledge of health insurance processing. - Skilled with electronic medical record applications, automated encoders, and other software applications. - Heavy day to day communication and interaction with physicians. Requirements - Certified Coding Specialist (CCS) required or Certified Professional Coder (CPC) required. - Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT) preferred. Benefits - Monday to Friday: 9:00am to 5:00pm (Flexible). - Fully Remote (Texas Resident Only).

• Analyze inpatient medical records to extract comprehensive clinical, pathologic, and procedural data • Assign and sequence ICD-10-CM diagnoses and ICD-10-PCS procedures with highest specificity • Determine and accurately apply Present on Admission (POA) indicators for all applicable diagnoses • Review admission, discharge, and concurrent documentation to validate coding completeness and accuracy • Collaborate with clinical teams and query providers when documentation clarification is required • Ensure compliance with federal, state, and payer-specific inpatient coding and reporting guidelines • Support accurate MS-DRG assignment and reimbursement through thorough coding practices • Maintain integrity of coded data for quality reporting, research, and regulatory submissions • Meet productivity benchmarks while maintaining high-quality standards across assigned inpatient cases