Medical Coder II, Hospital-Based Coding

This position involves reviewing emergency, outpatient, and ambulatory medical records to identify elements for abstraction and to assign diagnostic and procedure codes. It includes beginning to review inpatient records. The role pursues effective relationships by sharing resources and feedback, applying up-to-date knowledge to meet deadlines, supporting documentation and coding compliance with laws and regulations, assisting in coding process updates, and accurately translating clinical information into codes following ICD-CM, CPT, and HCPCS Level II guidelines. The coder works under day-to-day supervision, assists in resolving coding issues in collaboration with clinicians and departments to reduce denials and improve submission times, and supports team consultations on coding and documentation queries.

Minimum qualifications include at least two years of experience with hospital ambulatory surgery, observation, home health/hospice (if applicable), and complex outpatient visits, capturing codes for procedures requiring monitored anesthesia and conscious sedation. A high school diploma or GED plus coding experience is required. Certifications required at hire include Registered Health Information Technician, Registered Health Information Administrator, or Certified Coding Specialist.

Knowledge in quality assurance, health care coding, data quality, medical terminology, compliance management, health records, and health information systems is essential.