Ste Genevieve County Memorial Hospital
Location
Ste. Genevieve, Missouri
The role involves performing prospective and retrospective audits of inpatient, outpatient, and clinic documentation and coding to validate ICD-10-CM, ICD-10-PCS, CPT, and HCPCS Level II codes for accuracy and compliance. This position also requires educating providers on documentation to support billed services and identifying patterns of risk, under-coding, or over-coding.
Candidates must possess required certifications such as CPC or CCS and have a minimum of 5 years of multi-specialty coding experience with ICD-10-CM, ICD-10-PCS, and CPT, including extensive knowledge of E/M leveling. Strong familiarity with CMS regulations, coding guidelines, and the ability to communicate complex concepts clearly to various stakeholders are essential.
Description HIM Coding and Documentation Educator – Health Information Management – Full Time
· Perform prospective and retrospective audits of inpatient, outpatient, and clinic encounter documentation and coding. · Validate ICD-10-CM, ICD-10-PCS, CPT, and HCPCS Level II codes for accuracy and compliance. · Review and educate providers on documentation to ensure medical necessity that supports provider and coder level of service billed, and alignment with coding and billing standards including HCC’s (e.g., CMS, OIG, MAC guidelines). · Identify patterns of risk, under-coding, over-coding, and potential compliance issues; prepare detailed audit findings and recommendations. · Collaborate with providers and coders to deliver targeted feedback, education, and training based on audit results. · Develop and implement corrective action plans in coordination with HIM leadership when deficiencies are identified. · Monitor regulatory updates and changes to coding guidelines, reimbursement policies, and documentation requirements. · Assist in preparing for external audits by payers or regulatory bodies, including documentation submission and response coordination. · Maintain audit logs, metrics, and reporting dashboards to track performance, trends, and areas of risk. · Support the ongoing development and implementation of internal auditing policies and procedures.
CPC, CCS · Minimum of 5 years ICD-10-CM, ICD-10-PCS, CPT 4 multi-specialty coding experience with an extensive knowledge of E/M leveling based on medical decision making. · Strong knowledge of CMS physician and ancillary documentation regulations, E/M, ICD-10-CM, AMA/CPT coding guidelines, and resources. · Familiarity with coding compliance tools, Meditech EMR system, and encoder software. · Demonstrated ability to interpret medical record content and communicate complex concepts to clinical and non-clinical stakeholders. · High attention to detail, strong analytical skills and ability to work independently.
RHIT or RHIA · Bachelor’s Degree referred · Prior experience in a Critical Access Hospital or rural health clinic (RHC) setting. · Certified Professional Medical Auditor (CPMA) or equivalent credential. · Knowledge of rural health billing, including UB-04 and CMS-150 claim from nuances.
Your next move.
Now that you know more about being a HIM Coding and Documentation Educator on our team, we hope you’ll join us. At SGCMH you’ll reaffirm every day how much you love this work, and why you were called to it in the first place. SGCMH is an equal opportunity employer. All recruiting, training, and employment decisions are made in accordance with applicable federal, state, and local laws and without regard to race, color, ancestry, national original gender, pregnancy, gender identity, sexual orientation, religion, age, disability, handicap, military or veteran status or any other legally protected status.
Market context
Missouri healthcare employers often seek coding educators who can support compliance, training, and documentation quality across multi-specialty settings. This role is competitive because it requires CPC or CCS certification, five years of multi-specialty coding experience, strong ICD-10-CM, ICD-10-PCS, CPT, and E/M leveling knowledge, plus familiarity with CMS regulations and coding guidelines. Review the AI-summarized requirements and benefits here to save time, then confirm your certification match and prepare examples of how you have taught coding or documentation improvements.
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