Medical Coder - Full Time

Indiana Regional Medical Center • Indiana, PA

44d • Onsite

About The Position

In this role you will review patient medical records and documentation to identify diagnoses and procedures. You will assign accurate and complete ICD-9-CM, CPT, and HCPCS codes based on clinical documentation and coding guidelines. You will ensure coding meets all federal, state, and payer-specific requirements. You will abstract and enter coded data into electronic health records and hospital information systems. You will collaborate with clinical staff or coding team leads to clarify documentation as needed. You will maintain productivity and accuracy standards in accordance with departmental policies. You will stay current with updates to coding regulations, coding clinics, and payer guidelines. You will adhere to HIPAA regulations and all hospital confidentiality and compliance standards. 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

• Basic knowledge of ICD-10-CM, CPT, and medical terminology.
• Strong attention to detail and analytical skills.
• Completion of the IRMC outpatient coding competency test

Nice To Haves

• Associate’s or bachelor’s in health information management or related field
• Certified coding specialist (CCS)
• Registered health information technician (RHIT)

Responsibilities

• Review patient medical records and documentation to identify diagnoses and procedures.
• Assign accurate and complete ICD-9-CM, CPT, and HCPCS codes based on clinical documentation and coding guidelines.
• Ensure coding meets all federal, state, and payer-specific requirements.
• Abstract and enter coded data into electronic health records and hospital information systems.
• Collaborate with clinical staff or coding team leads to clarify documentation as needed.
• Maintain productivity and accuracy standards in accordance with departmental policies.
• Stay current with updates to coding regulations, coding clinics, and payer guidelines.
• Adhere to HIPAA regulations and all hospital confidentiality and compliance standards.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED