The Medical Coder reviews, evaluates, and analyzes inpatient and outpatient medical records to ensure accurate diagnostic and procedural coding, complete medical record abstraction, and appropriate healthcare reimbursement. This role requires a strong understanding of medical terminology, anatomy, physiology, pathology, ICD-10-CM, and CPT-4 coding systems, along with experience interpreting healthcare documentation and applying coding regulations.
Responsibilities
Review and evaluate inpatient and outpatient medical records to extract accurate diagnostic, procedural, and demographic information
Assign appropriate diagnosis and procedure codes using applicable ICD-10-CM and CPT coding guidelines and regulations
Apply current coding standards and reimbursement requirements to support accurate and appropriate financial reimbursement
Ensure correct code selection, sequencing, and documentation of diagnoses and procedures
Identify incomplete, unclear, inconsistent, or questionable medical documentation and refer cases to the attending physician, Medical Records Director, or Medical Director for clarification and resolution
Provide coding guidance and technical assistance to physicians, medical records personnel, and billing staff
Collaborate with the billing department to maintain accurate data, support internal controls, and minimize coding and billing errors
Verify information documented on patient abstract forms, including applicable PSI abstract forms, and review supporting information for accuracy and completeness
Use computer systems and healthcare databases to verify patient coverage, insurance eligibility, and applicable reimbursement requirements
Ensure coded and abstracted medical records are completed and forwarded to the billing department in a timely manner
Maintain a weekly status log of admissions, transfers, and discharges to track medical records and ensure records are accounted for and completed
Abstract and enter accurate medical information into financial, statistical, and billing databases
Maintain strict confidentiality of patient health information and comply with applicable privacy policies and regulations, including HIPAA
Assist supervisors and medical staff with additional medical records, coding, documentation, and reimbursement-related duties as assigned
Requirements
Extensive knowledge of medical terminology, anatomy, physiology, pathology, pharmacology, diagnostic testing, and medical procedures
Strong working knowledge of ICD-10-CM and CPT-4 coding classification systems and applicable coding guidelines
Understanding of Medicare, Medicaid, commercial insurance, and other third-party payer requirements
Knowledge of healthcare billing, reimbursement policies, and medical record documentation standards
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Ability to accurately interpret clinical documentation and assign appropriate diagnosis and procedure codes
Ability to identify documentation deficiencies and communicate effectively with physicians and other healthcare professionals to obtain clarification
Strong analytical, organizational, problem-solving, and data abstraction skills
Proficiency in electronic medical records, coding software, and healthcare information systems
Excellent written and verbal communication skills and the ability to collaborate across clinical, medical records, and billing departments
Demonstrated commitment to accuracy, confidentiality, compliance, and timely completion of assigned work
Graduation from an accredited college with a specialization in medical records science or health information management
Graduation from an approved nursing school, together with Certified Coding Specialist (CCS) certification through the American Health Information Management Association (AHIMA)
Certified Professional Coder (CPC) certification through the American Academy of Professional Coders (AAPC), as applicable to the employer's requirements
An equivalent combination of education, professional certification, and relevant experience that demonstrates the required knowledge and competencies
Previous employment as a Medical Coder, Coding Abstractor, Coding Specialist, or in a comparable medical records coding position
Experience reviewing inpatient and outpatient medical records and applying CPT coding standards in a hospital reimbursement environment
Demonstrated ability to abstract medical information, support billing processes, and resolve coding or documentation discrepancies
Nice to have:
Experience in an acute-care hospital or other approved inpatient/outpatient healthcare facility
Experience with medical record abstraction, coding audits, reimbursement review, and billing data validation
Familiarity with healthcare payer policies and electronic health record systems
Current professional coding certification, such as CCS or CPC
Important Details
Schedule: 8:30 AM - 4:00 PM (Monday-Friday)
Department: Medical Records / Health Information Management
About the Company
The Medical Coder will collaborate with physicians, medical records personnel, billing staff, and other healthcare professionals to resolve documentation discrepancies, maintain accurate patient records, and support timely and compliant billing and reimbursement processes.
In a world that is increasingly focused on transactions, we are focused on relationships.
