Coder / Abstractor, Full-Time

Description

HI Coder/Abstractor

Department: Health Information

Job Type: Full-time, 80 hours bi-weekly

Shift: First shift

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Job Description:

Fulton County Health Center is seeking a detail-oriented Inpatient Coder/Abstractor to join the Health Information team. This position is responsible for accurately coding and abstracting medical records across all hospital service types, ensuring data integrity, regulatory compliance, complete documentation, timely electronic data entry, and support of clinical and statistical reporting. The ideal candidate is passionate about healthcare documentation, quality data management, and maintaining accurate patient health information.

Key Responsibilities:

• Review medical records and assign diagnosis and procedure codes using ICD-10-CM/PCS and CPT-4 in accordance with Critical Access Hospital reporting requirements and UHDDS guidelines.
• Abstract and sequence clinical data from medical records while maintaining compliance with coding standards and regulatory requirements.
• Perform chart analysis during the coding and abstracting process to ensure documentation is complete, accurate, and compliant.
• Generate clinical and statistical reports and respond to internal data requests.
• Maintain compliance with departmental, hospital, and regulatory coding policies and procedures.
• Participate in quality assurance initiatives and support performance improvement activities through accurate clinical data.
• Identify and communicate incomplete, conflicting, or inconsistent documentation within the medical record.
• Assist with maintaining the Master Patient Index and ensure accurate patient identification.
• Provide cross-functional support within the Health Information Department as departmental needs evolve.
• Comply with all applicable laws, regulations, and Fulton County Health Center policies and procedures, including HealthStream education and Policy Manager requirements.
• Maintain a professional appearance and demonstrate exceptional customer service while promoting a safe environment for patients, visitors, and fellow employees.
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Requirements

• High school diploma or equivalent required.
• RHIT or CCS credential required. Candidates actively pursuing an AHIMA-accredited credential may be considered if completion is expected within six (6) months of hire. Required credential(s) must be maintained as a condition of employment.
• Ongoing participation in continuing education and professional development is expected.
• Proficiency with MEDITECH, Microsoft Word, Excel, PowerPoint, and encoder software (3M preferred).
• Knowledge of ICD-10-CM/PCS, CPT-4, UHDDS guidelines, and Critical Access Hospital coding requirements.
• Familiarity with medical terminology, anatomy, physiology, procedures, and clinical documentation.
• Ability to accurately abstract clinical information and communicate data clearly.
• Strong attention to detail with excellent analytical and organizational skills.
• Strong memory and ability to interpret complex clinical information.
• Effective interpersonal and communication skills to work collaboratively with physicians, clinical staff, and external agencies.
• Competency with electronic medical record (EMR) systems and document imaging software.