Position Summary:

The Medical Coder is responsible for reviewing patient medical records and accurately assigning diagnosis and procedure codes using current ICD coding standards and applicable regulatory guidelines. This position ensures the integrity, accuracy, and completeness of coded data for billing, reporting, reimbursement, and quality improvement purposes. The Medical Coder also assists with medical record abstraction, reporting, and communication with providers regarding documentation requirements.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Review patients' complete medical records and assign appropriate diagnosis codes using the International Classification of Diseases (ICD) system. Determine the correct sequencing of diagnoses in accordance with Uniform Hospital Discharge Data Set (UHDDS) guidelines and applicable coding standards. Assign appropriate procedure codes for surgical and designated diagnostic procedures. Record and maintain required data elements including attending physician, consultations, referral sources, and other applicable information. Query providers when documentation is incomplete, inconsistent, or unclear to ensure accurate code assignment. Maintain current knowledge of coding regulations, procedures, and industry guidelines. Monitor coding accuracy and quality through periodic reviews, audits, and analysis of coding corrections identified through computerized edits. Abstract clinical and administrative data within MIRA and other applicable systems for reporting to regulatory agencies, third-party payers, providers, and hospital administration. Serve as a liaison between hospital departments, medical staff, and external agencies regarding coding assignments and operational issues. Prepare periodic reports and other documentation as requested. Attend continuing education courses, seminars, and training programs to maintain coding proficiency and certification requirements. Provide assistance with departmental and office functions as assigned. HIM Clerk duties, like records request, recording QI and spreadsheets

Education:

Associate degree in Health Information Management or a related field preferred. Certification as a Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS) or Certified Professional Coder (CPC).

Experience:

Previous medical coding experience preferred General office and computer experience required Experience with Electronic Health Record (EHR) systems preferred

Certifications, Licenses, and Registrations:

Current RHIT certification or other approved coding certification required. Knowledge, Skills, and Abilities Knowledge of ICD coding systems and applicable healthcare regulations. Strong attention to detail and accuracy. Ability to interpret and apply coding guidelines and standards. Ability to work independently and meet deadlines. Strong analytical, problem-solving, and critical-thinking skills. Ability to carry out detailed written and verbal instructions. Effective written and verbal communication skills. Proficiency with computer applications, EHR systems, and medical record software. Ability to collect data, establish facts, and draw valid conclusions. Ability to manage multiple tasks and frequent interruptions. Behavioral Competencies Demonstrates professionalism and confidentiality. Works cooperatively with all hospital departments and members of the medical staff. Maintains positive working relationships with providers, coworkers, and external agencies. Demonstrates flexibility and adaptability in a changing healthcare environment. Working Conditions Primarily sedentary work environment. Frequent use of computers and office equipment. Subject to frequent interruptions and changing priorities. May be exposed to biohazardous materials, radioactive substances, and toxic chemicals in the healthcare environment. Requires the ability to learn and adapt to changes in EHR systems and coding requirements. Physical Requirements Manual dexterity and hand-eye coordination sufficient to operate office equipment and computers. Ability to hear and communicate effectively, with or without reasonable accommodation. Occasional lifting and carrying of up to 50 pounds. Occasionally prolonged sitting, standing, and walking. Frequent reaching, stooping, bending, kneeling, and crouching. Ability to perform work requires sustained concentration and attention to detail. This position is an on‑site role and is not eligible for remote or telecommuting work. Regular, in‑person attendance at the designated work location is an essential function of the position. This job description is not intended to be an exhaustive list of all duties, responsibilities, or qualifications associated with the position. 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