Medical Coder

Signature Performance, Inc. • ,

1d

About The Position

The Medical Coder reviews paper and electronic medical records to accurately assign diagnoses and procedures using medical documentation, coding guidelines, and knowledge of anatomy, physiology, medical terminology, and pathology. The role covers E&M, ICD-10-CM, ICD-10-PCS, CPT, and HCPCS coding, including modifiers and quantities, as appropriate to the record type.

The coder reviews relevant clinical records, determines diagnoses treated, monitored, and evaluated and procedures performed, and assigns and sequences codes according to their clinical significance. Coding must follow official guidelines and applicable federal, insurance, CMS, JCAHO, and client requirements, supporting accurate DRG, APC, or other prospective-payment reimbursement. The coder checks work for accuracy and completeness before billing submission, abstracts medical and demographic data into systems, and corrects discrepancies between records and system entries. The role also includes identifying missing or conflicting documentation, preparing physician queries, using coding-related computer applications and resources, and meeting quality and quantity expectations.

Requirements

• At least 2 years of medical coding experience.
• Experience with professional fee coding.
• Experience with EHR systems.
• An accepted AHIMA or AAPC certification, with requirements varying according to assigned coding: RHIT, RHIA, CCA, CCS, CCS-P, or CPC.

Responsibilities

• Assign principal and secondary diagnoses and procedures through thorough review of medical record documentation.
• Review discharge summaries, histories and physicals, progress notes, consultation reports, radiology, laboratory and pathology records, operative records, and emergency room records.
• Determine which diagnoses were treated, monitored, or evaluated and which procedures were performed during the episode of care, then assign appropriate codes.
• Select codes in accordance with Official Coding Guidelines and applicable federal and insurance regulations.
• Sequence diagnoses and procedures by clinical significance to support appropriate DRG, APC, or payment-tier assignment under the Prospective Payment system.
• Review coding for accuracy and completeness before submission to billing.
• Abstract required medical and demographic information from medical records and enter it accurately into the system.
• Correct erroneous data by reviewing medical records and comparing them with system entries.
• Ensure coding-related medical record components are present, accurate, and compliant with CMS, JCAHO, and client requirements.
• Identify incomplete or conflicting documentation and formulate physician queries to obtain missing information or clarification.
• Use computer applications and resources needed to complete coding efficiently.
• Meet coding quality and quantity expectations.

Benefits

• Health insurance.
• Fully paid life insurance.
• Fully paid short- and long-term disability.
• Paid vacation.
• Paid sick leave.
• Paid holidays.
• Professional development and tuition assistance program.
• 401(k) program with employer match.
• Competitive pay and position-specific incentives.
• Training and development, resources, and events.

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed