Medical Records Coder-Senior

Job Description

Under limited supervision, responsible for conducting the quality review of inpatient and outpatient coding, assures coding compliance with federal regulations, and maintains up-to-date coding guidelines and coding policy changes.

Responsibilities

• Reviews, interprets, and assigns diagnostic and procedural codes based upon medical record documentation according to correct coding principles.
• Provides skilled and specialized technical work in documentation and coding for medical billing, abstracts complex patient-related data from medical records and coding of diagnoses and procedures using ICD-10 and CPT codes.
• Works coding related charge review and claim edits daily to ensure timely and accurate billing.
• Researches and resolves coding related issues, and assists in meeting productivity and quality standards.
• Contacts other facilities to obtain medical records and information need to bill for services rendered.
• Verifies fee tickets and physician notes for completeness to include abstracting and entering relevant medical information from the medical records; checks for required signatures; assures proper documentation guidelines are followed.
• Interacts with regulator classification agencies and patients when clarification and additional information is required for documentation.
• Reviews charge documents for completeness.
• Updates coding books with changes as accepted and published by regulatory agencies.
• Performs all other duties as assigned.

Qualifications

• Proficiency in ICD-10 and CPT coding.
• In-depth understanding of medical terminology, anatomy and physiology.
• Meticulous attention to detail and accuracy.
• A solid customer service acumen and interpersonal skills to effectively work with both internal and external customers and responds to requests in a timely and respectful manner.
• Strong verbal, written and interpersonal communication skills.

Education

• High school diploma or GED is required.

Required Skills

• Five (5) years experience in medical record abstraction and coding is required.