Medical Coder

Job Summary:

Coders must ensure accurate, compliant coding for billing and reporting purposes and meet quality (95%) and productivity standards set by the company or client.

Key Responsibilities:

• Code and abstract medical diagnoses, procedures, and treatments for inpatient, outpatient, or day surgery cases.
• Review provider documentation to identify principal diagnoses, co-morbidities, and performed procedures.
• Assign appropriate codes and classifications:
• Inpatient: ICD-10-CM, ICD-10-PCS, Present on Admission (POA), DRG, CC/MCC.
• Outpatient/Professional: ICD-10-CM, CPT, HCPCS, APC.
• Follow official coding guidelines and client-specific instructions.
• Submit queries to providers for clarification or improvement of documentation.
• Enter coding data into systems (encoder and abstracting tools).
• Report daily productivity and any issues to the supervisor.
• Flag and report improper coding or documentation issues.
• Maintain strict patient confidentiality.

Qualifications:

Knowledge & Skills:

Proficient in coding systems and guidelines (ICD-10, CPT, HCPCS, DRG, APC).

Skilled in using encoder tools and computer applications.

Strong analytical and communication skills.

Fluent in English.

Education:

Bachelor's degree in Medical Records or Allied Medical Field, or equivalent work experience.

Experience:

At least 1 year of coding experience in an acute care, clinic, or ED setting (6 months on live accounts).

Certifications:

AHIMA: CCA, CCS-P, CCS