Medical Coder

To assign and group diagnoses, procedure, and level codes based on medical record documentation in accordance with coding compliance, regulatory, and reimbursement requirements. This role ensures appropriate coding for case mix classification and expected reimbursement based on assigned diagnosis, procedure, and level codes and reimbursement classifications as supported by medical record documentation. It also includes entering diagnoses, procedure, and level codes and patient demographic information into the computer system.

• Analyze, sequence, and validate assigned codes using the automated encoder, book, and coding compliance resources.
• Apply coding rules, anatomy, physiology, and medical terminology to accurately code patient information.
• Review medical record documentation to assign diagnoses, procedures, level codes, and modifiers.
• Ensure coding compliance, regulatory, and reimbursement requirements are met.
• Abstract and enter demographic, clinical, and related patient information into the computer system.
• Assess documentation adequacy and query physicians and other healthcare providers for clarification when needed.
• Reconcile, identify, and retrieve medical records to be coded.
• Maintain a 95% ongoing accuracy rate.
• Meet daily coding productivity standards and submit claims timely.
• Maintain productivity logs and provide them to management.
• Assist in the orientation and development of new coding personnel.
• Support ongoing professional development to maintain active coding certification.
• Monitor documentation, performance, and workflow to identify problems and potential solutions.
• Communicate with the PB Coding Manager to improve productivity and department efficiency.
• Perform all duties in a professional manner and complete other related duties as assigned.