Medical Coder

The Medical Coder is responsible for reviewing clinical documentation and assigning

appropriate medical codes for diagnoses, procedures, and services performed by healthcare

providers. This role ensures accurate coding for billing, insurance claims, and regulatory

compliance. The Medical Coder plays a crucial role in maintaining accurate patient records and

supporting the financial health of the organization.

Primary Responsibilities:

• Review and analyze medical records to assign accurate ICD-10, CPT, and HCPCS codes for diagnoses, procedures, and services.
• Ensure coding compliance with federal regulations, payer policies, and industry standards.
• Abstract key information from medical records to complete coding assignments.
• Collaborate with providers and clinical staff to clarify documentation discrepancies or obtain missing details to ensure accurate coding.
• Submit coded claims to the billing department or electronic medical records (EMR) system for processing.
• Identify and correct coding errors to reduce claim denials and improve reimbursement.
• Stay current with coding guidelines, regulatory updates, and industry best practices.
• Participate in audits and quality improvement initiatives to ensure coding accuracy and compliance.
• Assist in training new staff on coding processes and documentation best practices as needed.
• Maintain confidentiality of patient information and adhere to HIPAA regulations at all times.

Education and Experience Requirements:

Education:

• High school diploma or equivalent required.
• Completion of an accredited Medical Coding program preferred.

Certification:

• Certification through AAPC (e.g., CPC, CPB) or AHIMA (e.g., CCA, CCS) required or
• must be obtained within a designated timeframe.

Experience:

• Minimum of one year of medical coding experience in a healthcare setting preferred.
• Strong understanding of medical terminology, anatomy, and physiology.

Skills and Abilities:

• Strong knowledge of ICD-10, CPT, and HCPCS coding systems.
• Proficiency in using Electronic Health Records (EHR) systems and coding software.
• Ability to read and interpret clinical documentation accurately.
• Strong analytical skills with excellent attention to detail.
• Effective communication skills for collaborating with providers and staff.
• Ability to manage time effectively and meet deadlines in a fast-paced environment.

Work Environment:

• Primarily an office environment with extended periods of sitting and computer use.
• May require occasional interaction with clinical staff to clarify documentation or coding
• details.

Key Attributes for Success:

• Strong organizational skills with the ability to manage multiple priorities.
• Commitment to accuracy, compliance, and maintaining confidentiality.
• Ability to adapt to changes in coding regulations and healthcare standards.