Coder - Full Time

Indiana Regional Medical Center • Indiana, PA

2d

About The Position

In this role you will be:

Review medical records and clinical documentation to assign accurate and
complete diagnosis and procedure codes.
Apply knowledge of coding systems (ICD-10-CM, ICD-10-PCS, CPT, HCPCS) and
coding guidelines (AHA Coding Clinic, CPT Assistant, etc.) to ensure proper
code selection.
Abstract and enter coded data into electronic health record (EHR) and
hospital information systems for billing and reporting purposes.
Ensure compliance with federal, state, and payer-specific coding regulations
and hospital policies.
Work closely with providers and clinical documentation improvement (CDI)
teams to clarify ambiguities or incomplete documentation.
Maintain productivity and coding accuracy benchmarks as defined by the
department.
Support audits and quality reviews by coding leadership or external bodies.
Assist with mentoring or training junior coding staff as needed.
Stay updated on coding changes, regulatory updates, and continuing education
requirements.

OTHER DUTIES

Please note this job description is not designed to cover or contain a
comprehensive listing of activities, duties, or responsibilities that are
required of the employee for this job. Duties, responsibilities, and activities
may change at any time with or without notice.

Requirements

• High school graduate or equivalent, associate’s or bachelor’s in health information management or related field preferred
• Coding in acute care hospital or physician office setting with multiple specialties
• Experience with data entry required
• Completion of the IRMC outpatient coding competency test

Nice To Haves

• Certified coding specialist (CCS) preferred or registered health information technician (RHIT) preferred

Responsibilities

• Review medical records and clinical documentation to assign accurate and complete diagnosis and procedure codes.
• Apply knowledge of coding systems (ICD-10-CM, ICD-10-PCS, CPT, HCPCS) and coding guidelines (AHA Coding Clinic, CPT Assistant, etc.) to ensure proper code selection.
• Abstract and enter coded data into electronic health record (EHR) and hospital information systems for billing and reporting purposes.
• Ensure compliance with federal, state, and payer-specific coding regulations and hospital policies.
• Work closely with providers and clinical documentation improvement (CDI) teams to clarify ambiguities or incomplete documentation.
• Maintain productivity and coding accuracy benchmarks as defined by the department.
• Support audits and quality reviews by coding leadership or external bodies.
• Assist with mentoring or training junior coding staff as needed.
• Stay updated on coding changes, regulatory updates, and continuing education requirements.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED
• Number of Employees: 251-500 employees