Coder, Medical Billing and Coding, Medical Records

About This Role

This role is for a detail-oriented and knowledgeable Certified Coding Specialist to support accurate medical coding, charge capture, documentation review, and regulatory compliance across multiple hospital and outpatient service areas. The specialist will review medical records, assign appropriate diagnosis and procedure codes, reconcile charges, support coding audits, and promote compliance with applicable coding guidelines and reimbursement requirements. This position works collaboratively with Health Information Management, clinical staff, providers, and other departments to ensure the accuracy, completeness, and integrity of coded health records.

Responsibilities

• Review medical records for documentation accuracy, completeness, and coding requirements
• Assign appropriate ICD-10-CM, ICD-10-PCS, CPT, and HCPCS codes in accordance with established coding guidelines
• Code inpatient, swing bed, Emergency Department, observation, same day surgery, endoscopy, Rural Health Clinic, and other outpatient encounters
• Review and reconcile charges to support accurate billing and reimbursement
• Identify documentation deficiencies and coordinate appropriate provider queries in accordance with established policies and compliance standards
• Support internal and external coding audits, record reviews, and corrective action activities
• Monitor compliance with applicable coding guidelines, regulatory requirements, and reimbursement standards
• Collaborate with clinical, billing, and Health Information Management staff to resolve coding and documentation discrepancies
• Participate in quality improvement initiatives and coding education as needed
• Maintain the confidentiality and security of patient health information in accordance with HIPAA and hospital policies
• Maintain required professional credentials and participate in continuing education to remain current with coding standards and industry changes
• Perform other related duties as assigned

Requirements

• High school diploma or equivalent required
• Current, active coding or health information management credential from AHIMA or AAPC, as specified below
• Ability to interpret medical documentation and apply appropriate coding guidelines across multiple healthcare settings
• Candidates must possess and maintain at least one current, active credential from the following list: AHIMA Certified Coding Specialist (CCS), Registered Health Information Administrator (RHIA), AAPC Certified Professional Coder (CPC)
• Certification must remain active throughout employment

Nice to have:

• CCS, RHIT, RHIA, or CIC certification
• Three or more years of medical coding experience