Medical Coder - On Site

Job Title: Medical Coder

Location: Greater Sacramento

Job Type: Full Time

About the Role:

The ICD-10 Home Health & Hospice Medical Coder is responsible for accurately reviewing, analyzing, and assigning ICD-10-CM diagnosis codes to clinical documentation for home health and hospice services. This role ensures compliance with CMS guidelines, OASIS requirements, and agency policies to support precise reimbursement, high-quality patient care, and regulatory compliance.
The ideal candidate has demonstrated experience in Home Health ICD-10 coding, strong knowledge of OASIS/Evaluation criteria, and a thorough understanding of PDGM (Patient-Driven Groupings Model).

Key Responsibilities

Coding & Documentation Review

  • Review clinical documentation to identify appropriate and accurate ICD-10-CM codes for home health and hospice encounters.
  • Assign primary and secondary diagnoses following CMS, PDGM, and regulatory requirements.
  • Validate medical necessity and ensure coding supports the plan of care and services rendered.
  • Review and interpret physician orders, clinical notes, OASIS assessments, and other documentation to ensure accurate code selection.

Quality, Compliance & Auditing

  • Ensure all coding aligns with CMS, industry, and agency standards, including PDGM/PEPPER guidelines.
  • Conduct self-audits or participate in agency coding audits to maintain accuracy and compliance.
  • Assist with corrections and updates based on audit findings or regulatory changes.
  • Maintain strict confidentiality and follow HIPAA requirements.

Collaboration & Communication

  • Communicate with clinicians, QA staff, and the billing department to clarify diagnoses, resolve documentation discrepancies, and improve coding accuracy.
  • Provide feedback to clinical staff regarding documentation gaps that impact coding or reimbursement.
  • Participate in training or educational sessions to enhance coding competency and knowledge of industry updates.

Data Integrity & Workflow Management

  • Complete coding assignments within established departmental timelines.
  • Ensure accurate and timely submission of coded encounters for billing and compliance.
  • Assist in optimizing coding workflows, documentation processes, and clinical data accuracy.

Required Qualifications

  • Minimum 2 years of Home Health ICD-10 coding experience (required).
  • Certification from a recognized credentialing body such as:
    • HCS-D (Home Care Coding Specialist–Diagnosis) – preferred
    • CPC, CCS, COC, or RHIT/RHIA accepted with Home Health-specific experience
  • Strong understanding of PDGM, OASIS documentation requirements, and Medicare regulations.
  • Experience with home health EMR systems (e.g., Homecare Homebase, WellSky/Kinnser, MatrixCare).
  • Excellent analytical, critical-thinking, and documentation review skills.
  • Strong understanding of pathophysiology, medical terminology, and clinical documentation requirements.

Preferred Qualifications

  • Hospice coding experience (ICD-10-CM) strongly preferred.
  • Knowledge of HIS (Hospice Item Set) and hospice regulatory requirements.
  • Experience working remotely or in a high-volume coding environment.
  • Familiarity with PEPPER reports and quality metrics for home health agencies.

Competencies & Skills

  • High level of accuracy and attention to detail.
  • Ability to interpret complex clinical notes and physician documentation.
  • Strong time management and organizational skills.
  • Excellent written and verbal communication abilities.
  • Self-motivated, able to work independently in a remote environment.
  • Ability to stay current with CMS updates, PDGM changes, and ICD-10 revisions.

Work Environment

  • Remote or on-site (depending on organization).
  • May involve occasional virtual meetings, trainings, or audit reviews.
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