In this role you will be: Review patient medical records and documentation to identify diagnoses and procedures. Assign accurate and complete ICD-9-CM, CPT, and HCPCS codes based on clinical documentation and coding guidelines. Ensure coding meets all federal, state, and payer-specific requirements. Abstract and enter coded data into electronic health records and hospital information systems. Collaborate with clinical staff or coding team leads to clarify documentation as needed. Maintain productivity and accuracy standards in accordance with departmental policies. Stay current with updates to coding regulations, coding clinics, and payer guidelines. Adhere to HIPAA regulations and all hospital confidentiality and compliance standards.

OTHER DUTIES

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.

QUALIFICATIONS

Required:

EDUCATION

High school graduate or equivalent, associate's or bachelor's in health information management or related field preferred

EXPERIENCE

Basic knowledge of ICD-10-CM, CPT, and medical terminology. Strong attention to detail and analytical skills.

LICENSURE/CERTIFICATION

Certified coding specialist (CCS) preferred or registered health information technician (RHIT) preferred Completion of the IRMC outpatient coding competency test