Nurse Medical Coder

Description

Job Summary: Seeking a Nurse Medical Coder to review medical records, assign diagnoses, identify missing information, and optimize processes. Key Highlights: 1. Solid experience in medical coding and terminology 2. Responsible for optimizing processes and reducing healthcare costs 3. Opportunity within one of the largest hospital groups in the country AREDE SANTA CATARINA **\- Casa de Saúde São José \-** is seeking a **Nurse Medical Coder** to join our team and contribute to our commitment to excellence in healthcare. **Education:** * Bachelor's degree in Nursing, with active registration at COREN and in good standing. * Postgraduate degree in related fields is desirable. **Requirements:** * Solid experience in this role; * Knowledge of medical terminology, anatomy, and physiology; * Familiarity with diagnostic methodology; internal norms, instructions, and procedures; **ICD-10**, primary and secondary diagnoses in patient medical records * Proficiency in Microsoft Office; **Responsibilities:** * Review medical records and assign correct diagnoses and procedures according to the adopted methodology. * Identify any missing or inaccurate information in medical records, collaborating with the clinical staff to ensure complete data. * Monitor and ensure compliance with deadlines for coding Hospital Admission Authorizations, extensions, and discharges. * Critically analyze the quality of services delivered, reporting technical discrepancies and identified inconsistencies to the immediate supervisor. * Assess and report opportunities for process improvement aimed at optimizing activities and reducing healthcare costs. * Register and validate data entered into the information system, such as diagnoses, procedures, staff, among others. * Provide technical guidance to team members, sharing information about the process across team members. * Report directly to the immediate supervisor regarding changes in routines by service providers, including modifications in professional, medical, and multidisciplinary team conduct. * Comply with legislation regulating professional practice and the Nursing Code of Ethics. * Perform duties in accordance with principles of quality management excellence, health, hygiene, safety, and environmental standards and policies of the Institution, aiming to maintain the physical integrity of employees and patients. * Record information inherent to the process for statistical analysis to support evaluations and decision-making. * Prepare and develop managerial reports, gathering financial information and tracking work progress and achieved results, aiming to provide strategic information for monitoring indicators and decision-making. * Comply with internal regulations, quality management system requirements, observance and implementation of regulations, as well as health, hygiene, and occupational safety standards and procedures relevant to the area of operation and use of PPEs/collective protective equipment (PPE/CPE) where required by the activity, and observe compliance, ESG, LGPD, and applicable institutional regulatory requirements. * Perform other duties inherent to the position or as assigned by the immediate supervisor, provided the individual is qualified and such duties align with their knowledge and experience. **Schedule:** * Availability for full-time work \| 200 hours – 8:00 AM to 5:00 PM; * 100% on-site; * Work location: Humaitá \- RJ. The Nurse Medical Coder will have the opportunity to join one of the largest hospital groups in the country, contributing to continuous improvement of healthcare services. Minimum Education Level: Postgraduate Specialization/MBA