Responsible for accurately assigning diagnostic, procedural, and infusion codes to emergency department, radiology, and other outpatient and facility encounter records. Reviews medical records, abstracts patient information, and forwards required reports.

Key responsibilities include:

Assign ICD-10-CM, ICD-10-PCS, and CPT codes using encoder software and/or code books.
Review the full medical record to determine appropriate diagnoses, procedures, and sequencing.
Capture required abstracting data such as attending physician, discharge disposition, consultations, and referral source.
Query physicians or other providers when documentation is unclear or incomplete.
Support training on coding procedures and maintain department records, reports, and files.
Participate in education, in-service meetings, and month-end record closure and correction activities.

Requirements & Qualifications

High school diploma or equivalent.
At least 1 year of hospital experience preferred.
Computer skills required.
Certification required upon hire: CCS, CCA, CPC, CPC-A, CPC-H, COC, RHIA, or RHIT.
Strong knowledge of ICD-10 diagnosis and procedure coding, CPT, and infusion coding guidelines.
Epic and Solventum encoder experience preferred.

Benefits & Perks

Employee portion of medical plan premiums covered after 3 years.
4%–10% employee savings plan match based on tenure.
Paid parental leave up to 12 weeks.
Caregiver leave.
Adoption and surrogacy reimbursement.

Certified Medical Records Coder