Medical Coder - Full Time

IRMC Career • Indiana, PA

9d

About The Position

In this role you will review medical records and clinical documentation to assign accurate and complete diagnosis and procedure codes. You will apply knowledge of coding systems (ICD-9-CM, ICD-9-PCS, CPT, HCPCS) and coding guidelines (AHA Coding Clinic, CPT Assistant, etc.) to ensure proper code selection. You will abstract and enter coded data into electronic health record (EHR) and hospital information systems for billing and reporting purposes. You will ensure compliance with federal, state, and payer-specific coding regulations and hospital policies. You will work closely with providers and clinical documentation improvement (CDI) teams to clarify ambiguities or incomplete documentation. You will maintain productivity and coding accuracy benchmarks as defined by the department. You will support audits and quality reviews by coding leadership or external bodies. You will assist with mentoring or training junior coding staff as needed. You will stay updated on coding changes, regulatory updates, and continuing education requirements. 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
• Experience with data entry required
• Registered health information technician (RHIT) required
• Completion of the IRMC outpatient coding competency test

Nice To Haves

• Associate’s or bachelor’s in health information management or related field preferred
• 3 years coding in acute care hospital or physician office setting with multiple specialties preferred
• Certified coding specialist (CCS) preferred

Responsibilities

• Review medical records and clinical documentation to assign accurate and complete diagnosis and procedure codes.
• Apply knowledge of coding systems (ICD-9-CM, ICD-9-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: Mid Level
• Education Level: High school or GED