Medical Records Technician (Coder)

Duties

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Reviews outpatient and observation records for completeness, accuracy, and compliance with regulatory and coding requirements, including high-acuity and time sensitive encounters.

Performs quantitative and qualitative analysis of medical records to verify required components (patient identifiers, signatures, dates, orders, reports, and time-based documentation) and to evaluate documentation for consistency, accuracy, medical necessity, and appropriate modifier usage.

Ensures final diagnoses accurately reflect care provided and are supported by provider documentation.

Ensures documentation corrections are completed within required timeframes to support timely coding, billing, quality reporting, and performance measurement.