HIM Certified Coder

Job Description

Job Description

Job Summary:

The Medical Coder is responsible for accurate coding, abstraction, and auditing of patient encounters to support compliant reimbursement, reporting, and regulatory requirements. This role reviews medical records to ensure documentation integrity, identifies diagnostic and procedural information, and validates that services rendered are fully supported by clinical documentation. The Medical Coder serves as a subject matter expert and consultant to providers and coding staff, identifies discrepancies and opportunities for improvement, and supports ongoing education, quality initiatives, and special projects.

Essential Duties/Responsibilites include but are not limited to:

• Diagnosis coding for all services, inpatient and outpatient

• Procedural coding for outpatient and inpatient services

• Auditing of charges for outpatient services

• Assists in documentation audits as needed

• Abstracting

• Maintains current coding competence regarding ICD-10-CM, ICD-10-PCS, CPT and

HCPCS coding guidelines, hospital guidelines/requirements, as well as third party payer

guidelines and policies and CMS coding guidelines as applicable

• Understands and utilizes physician query guidelines

• Performance Improvement trending

• Trauma Registries (as assigned)

Required Qualifications:

-Certification: AHIMA/AAPC Certified Coder (CCS, CPC, RHIT, RHIA, etc.)

-Experience in ICD-10-CM, ICD-10-PCS, CPT and HCPCS Level II.

-Experience in coding of inpatient, outpatient encounters or Rural Health Clinic/Pro Fee Coding

-Strong knowledge of anatomy, physiology, and medical terminology

-Excellent typing and 10-key speed and accuracy

-Strong Communication, problem solving, planning, attention to detail, and customer service skills

-Working knowledge of hospital information systems, medical jargon, and anatomy

-Able to work independently and maintain confidentiality.