The Coder I is responsible for reviewing health care documentation to determine diagnostic codes for billing purposes. They accurately sequence codes following departmental and AHIMA guidelines and ensure records are coded accurately and timely.

Key responsibilities include reviewing charts to identify all diagnoses and procedures, ensuring physician orders are received for ancillary tests, and using computerized coding systems to assign proper codes. The coder contacts physicians professionally if diagnosis information is unclear and maintains communication with the supervisor regarding uncoded charts. Productivity and quality standards of 95% or greater must be met.

The role requires familiarity with multiple manuals (Administrative, Departmental, Safety, Emergency Preparedness), completion of annual educational requirements, confidentiality adherence, and compliance with dress code.

Requirements include AAPC or AHIMA credential within 12 months of employment, preferably a Bachelor’s or Associate’s Degree in Health Information Management, or one year of formal education beyond high school. Medical terminology knowledge and six months related experience in an acute care facility are preferred. Candidates must pass a Clerical Ability Test (minimum 80%) and have a typing speed of 30 WPM.

Basic computer skills are needed; use of 3M Coding Software is preferred. Physical demands include near vision and hearing acuity. Reasonable accommodations for disabilities may be provided without compromising client care.