Medical Coder

Job Summary

We are looking for a detail-oriented and knowledgeable Medical Coder to accurately review, interpret, and assign medical codes based on clinical documentation, diagnoses, procedures, and services provided. The successful candidate will ensure accurate coding, proper documentation, and compliance with applicable coding standards and healthcare regulations.

Key Responsibilities

• Review medical records, clinical documentation, diagnoses, procedures, and treatment information to assign accurate medical codes.
• Assign appropriate ICD-10-CM, CPT, and HCPCS codes based on medical documentation.
• Ensure coding accuracy, completeness, and compliance with established coding guidelines and regulations.
• Validate medical documentation and identify missing, inconsistent, or unclear information that may affect coding.
• Collaborate with physicians, healthcare professionals, and internal teams to clarify documentation and coding requirements when necessary.
• Conduct coding audits and identify potential errors, discrepancies, or areas for improvement.
• Maintain confidentiality and security of patient and medical information.
• Stay updated on changes to coding guidelines, healthcare regulations, payer requirements, and industry standards.
• Assist in resolving coding-related discrepancies, denials, and documentation issues.
• Meet established productivity, quality, and accuracy standards.
• Prepare and maintain coding-related reports and documentation as required.
• Perform other related duties that may be assigned by management.

Qualifications

• Bachelor's degree in Health Information Management, Medical Coding, Nursing, Allied Health, or a related healthcare field is preferred.

• Must hold at least one of the following active certifications:

  • Certified Professional Coder (CPC)
  • Certified Coding Specialist (CCS)
  • Certified Inpatient Coder (CIC)

• Previous experience in medical coding, healthcare documentation, medical billing, or a related field is preferred.

• Strong knowledge of ICD-10-CM, CPT, and HCPCS coding systems.

• Familiarity with medical terminology, anatomy, physiology, and clinical documentation.

• Strong attention to detail and excellent analytical skills.

• Ability to interpret complex medical records and clinical documentation accurately.

• Knowledge of healthcare compliance and coding guidelines.

• Excellent written and verbal communication skills.

• Ability to work independently while meeting productivity and quality targets.

• Strong organizational and time-management skills.

• Proficiency in Microsoft Office and familiarity with Electronic Health Records (EHR) or coding software is an advantage.