Medical Coder
As a Medical Coder, you will play a crucial role in ensuring the accuracy and efficiency of billing processes by translating medical procedures, diagnoses, and services into standardized codes. Your expertise will contribute directly to timely and accurate reimbursement, compliance with regulations, and the integrity of our patient data.
Responsibilities
- Accurate Coding: Review patient medical records, including physician notes, operative reports, laboratory and radiology results, and discharge summaries, to identify relevant diagnoses, procedures, and services.
- Code Assignment: Assign accurate and appropriate ICD-10-CM, CPT, and HCPCS codes in accordance with official coding guidelines and regulations.
- Compliance: Adhere to all coding guidelines, legal and regulatory requirements, and company policies and procedures.
- Documentation Review: Identify and analyze documentation deficiencies and inconsistencies and collaborate with physicians and other healthcare professionals to obtain clarification and ensure complete and accurate coding.
- Abstracting Information: Extract pertinent information from medical records, including patient demographics, diagnoses, procedures, and dates of service.
- Data Entry: Accurately enter coded data and other relevant information into billing and abstracting systems.
- Coding Audits: Participate in internal and external coding audits to ensure accuracy and compliance.
- Staying Updated: Keep abreast of changes in coding guidelines, regulations, and reimbursement policies through ongoing education and professional development.
- Communication: Communicate effectively with billing staff, physicians, and other healthcare personnel regarding coding-related issues and clarifications.
- Problem Solving: Research and resolve coding discrepancies and denials.
- Confidentiality: Maintain the confidentiality of patient information in compliance with HIPAA regulations.
Qualifications
- High school diploma or equivalent required; associate or bachelor’s degree in health information management or a related field preferred.
- Years of experience in medical coding, preferably in medical specialty, e.g., inpatient, outpatient, surgery.
- Professional coding certification from AAPC (e.g., CPC, COC) or AHIMA (e.g., CCS, CCS-P) is highly preferred or required.
- Thorough knowledge of ICD-10-CM, CPT, and HCPCS coding systems and guidelines.
- Strong understanding of medical terminology, anatomy, physiology, and pathophysiology.
- Familiarity with healthcare billing processes and reimbursement methodologies.
- Proficiency in using electronic health record (EHR) systems and coding software.
- Excellent attention to detail and accuracy.
- Strong analytical and problem-solving skills.
- Effective written and verbal communication skills.
- Ability to work independently and as part of a team.
- Strong organizational and time-management skills.
- Commitment to maintaining patient confidentiality and ethical coding practices.
Preferred Skills
- Experience with EHR or billing systems.
- Knowledge of payer guidelines or regulations.
- Experience performing coding audits.