Medical Records Coder-Senior

Under limited supervision, responsible for conducting the quality review of inpatient and outpatient coding, assures coding compliance with federal regulations, and maintains up-to-date coding guidelines and coding policy changes.

• Reviews, interprets, and assigns diagnostic and procedural codes based upon medical record documentation according to correct coding principles.

• Provides skilled and specialized technical work in documentation and coding for medical billing, abstracts complex patient-related data from medical records and coding of diagnoses and procedures using ICD-10 and CPT codes.

• Works coding related charge review and claim edits daily to ensure timely and accurate billing.

• Researches and resolves coding related issues, and assists in meeting productivity and quality standards.

• Contacts other facilities to obtain medical records and information need to bill for services rendered.

• Verifies fee tickets and physician notes for completeness to include abstracting and entering relevant medical information from the medical records; checks for required signatures; assures proper documentation guidelines are followed.

• Interacts with regulator classification agencies and patients when clarification and additional information is required for documentation.

• Reviews charge documents for completeness.

• Updates coding books with changes as accepted and published by regulatory agencies.

• Performs all other duties as assigned.

• Proficiency in ICD-10 and CPT coding.

• In-depth understanding of medical terminology, anatomy and physiology.

• Meticulous attention to detail and accuracy.

• A solid customer service acumen and interpersonal skills to effectively work with both internal and external customers and responds to requests in a timely and respectful manner.

• Strong verbal, written and interpersonal communication skills.

Education

• High school diploma or GED is required.