The Clinic Coder, reporting to the Health Information Management (HIM) Manager, is responsible for reviewing medical record documentation and assigning accurate diagnosis and procedure codes. This role includes analyzing and auditing medical records for completeness and proper documentation, assisting the business office with coding issues, and maintaining compliance with current state and federal coding guidelines.

Key responsibilities include:

Coding and abstracting medical records using ICD-10-CM, ICD-10-PCS, and CPT codes
Assisting Billers with coding-related questions
Communicating routinely with physicians about diagnoses, procedures, and documentation
Querying physicians and healthcare providers when documentation is unclear or ambiguous
Auditing medical records for completeness and accuracy
Analyzing records for physician deficiencies and updating EMR accordingly
Handling telephone inquiries and processing record copies/faxes
Monitoring unbilled records reports
Maintaining hospital and departmental policies and confidentiality
Participating in Quality Assessment activities to improve patient care and hospital business

Licensure and Certification required:

Registered Health Information Technician (RHIT), or
Registered Health Information Administrator (RHIA), or
Certified Coding Specialist (CCS or CCS-P), or
Certified Professional Coder (CPC)

Experience:

At least two years of coding experience is required.

Environmental and Physical Requirements:

Ability to read, speak English fluently, strong math, reading, computer, and communication skills
Vision for near, mid-range, and far distances
Hearing across a wide range of pitches
Ability to sit for prolonged periods with minimal physical exertion
Some lifting up to 20-30 pounds

Equal Employment Opportunity and ADA considerations are in place. Reasonable accommodations are provided upon request.