Reviews and analyzes medical records to assign appropriate diagnostic and procedural codes in compliance with established coding guidelines and organizational policies. Collaborates with healthcare providers to clarify documentation and resolves coding discrepancies, ensures the integrity of coded data for billing and reporting purposes. Maintains current knowledge of coding standards such as ICD, CPT, and HCPCS, and supports the billing department by providing precise coded information for claims submission. Includes auditing coded data, training staff on coding procedures, and monitoring coding productivity and quality metrics to enhance departmental performance
• Reviews and analyzes medical records to assign appropriate diagnostic and procedural codes.
• Ensures compliance with coding guidelines and organizational policies.
• Collaborates with healthcare providers to clarify documentation.
• Resolves coding discrepancies and maintains data integrity.
• Supports billing department with accurate coded information for claims.
• Audits coded data and monitors productivity and quality metrics.
• Trains staff on coding procedures and updates.
• Three (3) or more years of experience in medical coding and Health Information Management (HIM).
• Expertise in coding compliance, quality assurance, and coding audits.
• Experience coordinating coder training, mentoring, and performance monitoring.
• Knowledge of ICD-10-CM/PCS, CPT, and HCPCS coding standards and guidelines.
• Strong collaboration and communication skills when working with clinical providers and interdisciplinary teams.
Preferred Experience
• Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), or Certified Professional Coder (CPC).
• AHIMA Certified ICD-10-CM/PCS Trainer preferred.
• Minimum of five (5) years of hospital inpatient and/or outpatient coding and reimbursement experience.
• One (1) year of supervisory or team lead experience.
• Proficiency with Microsoft Windows and Microsoft Office (Word, Excel, PowerPoint).
• Ability to work independently with minimal supervision.
• Strong written, verbal, and interpersonal communication skills.
• Ability to build positive working relationships with clinical, operational, and coding teams.
• Equivalent combinations of education and experience may be considered.
Licensure / Certification
• RHIA – Registered Health Information Administrator.
• RHIT – Registered Health Information Technician.
• CCS – Certified Coding Specialist.
• CPC – Certified Professional Coder.