Medical Coder

Assign and group diagnoses, procedure, and level codes based on medical record documentation in accordance with coding compliance, regulatory, and reimbursement requirements. Enter diagnoses, procedure, level codes, and patient demographic information into the computer system.

Responsibilities include:

• Analyze, sequence, and validate assigned codes using the automated encoder, reference books, and coding compliance resources.
• Apply knowledge of 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 or other healthcare providers when clarification is needed.
• Reconcile, identify, and retrieve medical records to be coded.
• Maintain a 95% ongoing accuracy rate and meet daily productivity standards.
• Maintain accurate productivity logs and submit them to management timely.
• Assist in the orientation and development of new coding personnel.
• Maintain active coding certification through ongoing professional development.
• Monitor documentation, performance, and workflow to identify issues and support solutions related to errors and compliance.
• Perform duties professionally and carry out other related assignments as needed.