CODER / ABSTRACTOR, Contingent
About The Position
Fulton County Health Center is seeking a detail-oriented Inpatient Coder/Abstractor to join the Health Information team. This contingent position is responsible for accurately coding and abstracting medical records across hospital service types, maintaining data integrity and regulatory compliance, supporting complete documentation and timely electronic data entry, and contributing to clinical and statistical reporting. The role also supports quality data management and accurate patient health information. The position reviews and analyzes medical records, assigns and sequences diagnosis and procedure codes, abstracts clinical data, identifies documentation issues, and assists with patient identification and departmental support. It requires compliance with coding standards, applicable regulations, hospital policies, and departmental procedures, as well as professional customer service and participation in ongoing education and quality improvement.
Requirements
- High school diploma or equivalent.
- RHIT or CCS credential; candidates pursuing an AHIMA-accredited credential may be considered if completion is expected within six months of hire.
- Maintain required credential(s) as a condition of employment.
- Proficiency with MEDITECH, Microsoft Word, Excel, PowerPoint, and encoder software.
- Knowledge of ICD-10-CM/PCS, CPT-4, UHDDS guidelines, and Critical Access Hospital coding requirements.
- Familiarity with medical terminology, anatomy, physiology, procedures, and clinical documentation.
- Ability to accurately abstract clinical information and communicate data clearly.
- Strong attention to detail, analytical skills, and organizational skills.
- Strong memory and ability to interpret complex clinical information.
- Effective interpersonal and communication skills for collaboration with physicians, clinical staff, and external agencies.
- Competency with electronic medical record (EMR) systems and document imaging software.
Nice To Haves
- Experience with 3M encoder software is preferred.
Responsibilities
- Review medical records and assign diagnosis and procedure codes using ICD-10-CM/PCS and CPT-4 in accordance with Critical Access Hospital reporting requirements and UHDDS guidelines.
- Abstract and sequence clinical data from medical records while maintaining compliance with coding standards and regulatory requirements.
- Analyze charts during coding and abstracting to ensure documentation is complete, accurate, and compliant.
- Generate clinical and statistical reports and respond to internal data requests.
- Maintain compliance with departmental, hospital, and regulatory coding policies and procedures.
- Participate in quality assurance initiatives and support performance improvement activities through accurate clinical data.
- Identify and communicate incomplete, conflicting, or inconsistent documentation in medical records.
- Assist with maintaining the Master Patient Index and ensuring accurate patient identification.
- Provide cross-functional support within the Health Information Department as departmental needs evolve.
- Comply with applicable laws, regulations, Fulton County Health Center policies and procedures, HealthStream education, and Policy Manager requirements.
- Maintain a professional appearance, demonstrate exceptional customer service, and promote a safe environment for patients, visitors, and employees.
- Participate in continuing education and professional development.
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What This Job Offers
Education Level
High school or GED
