Medical Coder II

The entry-level medical coder is responsible for documentation improvement and integrity and serves as a liaison between clinical care providers, finance, and billers. This role provides proactive and retrospective review of health center visits related to ICD-10-CM diagnosis coding and reimbursement. The coder audits medical records to ensure completeness, accuracy, and compliance with Medicaid coding and supporting documentation guidelines.

Key responsibilities include:

• Evaluating medical record documentation for completion to ensure accuracy and compliance with Medicaid and ICD-10-CM standards
• Comparing past and present medical history to maintain complete and accurate ICD-10 codes for appropriate reimbursement
• Reviewing medical records prospectively to ensure patient care is recorded in language payers can interpret and that accurately reflects acuity and resources expended
• Working with the billing team to review records retrospectively and ensure accurate ICD-10 codes were selected by the provider
• Following coding compliance guidelines in all methods and processes
• Serving as a resource for clinical teams regarding risk adjustment and medical coding guidelines and updates
• Communicating documentation issues and variances to nursing staff, physicians, and mid-level practitioners
• Maintaining a continuous presence with clinical teams to foster trust, collaboration, and a culture of improvement
• Staying current on coding issues and regulatory changes through bulletins, AAPC resources, periodicals, and workshops
• Developing capability in Lean thinking and scientific problem-solving
• Maintaining and improving information systems used to track annual diagnosis capture rates and overall coding quality