Certified Medical Coder

Job Summary

Assist in coding medical documentation for physician office visits, procedures, and other services, ensuring accuracy and compliance with current CMS/AMA coding guidelines.

• Consistently and accurately assign ICD-10-CM, CPT, and/or HCPCS codes by reviewing and interpreting medical documentation from notes, orders, pathology, labs, etc.
• Identify and abstract any additional documented HCC diagnoses not listed by the provider in the Assessment/Impression/Final Diagnosis.
• Review and report missing or incomplete documentation.
• Query providers or clinic staff as necessary for clarification regarding documentation or lack thereof.
• Monitor assigned work lists and provider lists to ensure all records are coded in a timely manner.
• Meet departmental productivity standards for coding.
• Maintain current knowledge of medical compliance, coding guidelines, and federal regulations, including medical necessity issues and correct coding initiatives.
• Stay informed of changes/updates in ICD-10-CM/CPT guidelines by attending appropriate training and reviewing coding clinics.
• Meet continuing education requirements for coding certification and maintain annual compliance education.
• Participate in coding meetings and education conferences to maintain coding skills and accuracy.
• Attend conference calls as necessary to exchange information related to coding.

• Manage a significant workload efficiently under pressure, meeting established deadlines with minimal supervision.
• Demonstrate time awareness and minimize non-essential interruptions.
• Understand the impact of the position on the department, clinics, and hospital.
• Establish cooperative working relationships with all members of department, clinic, and hospital staff.
• Assist billing office staff with claims denials, verify billing data accuracy, and make corrections for re-billing as needed.
• Perform special projects as directed by the supervisor.
• Identify and communicate trends and educational opportunities to ensure proper documentation and billing accuracy.
• Respond to inquiries from providers, staff, and management in a timely and professional manner.
• Maintain organized, reliable attendance and dependability.
• Present to work on time as scheduled.
• Exhibit strong communication skills, both oral and written, with a friendly, helpful attitude.
• Demonstrate strong work ethic and flexibility.
• Apply analytical skills and sound judgment to make decisions.
• Self-motivate and problem-solve with a professional demeanor.
• Seek assistance from supervisor for schedule changes or work issues.
• Use available tools and equipment to get the job done.
• Proficiency in Microsoft Outlook, Excel, and Word.
• Work independently with minimal supervision.
• Perform other duties as assigned by supervisor.

• Knowledge of encoder systems (3M, Knowledge Source, Encoder Pro, Evident, etc.).
• Experience with CPT-4/HCPCS procedure coding.
• Experience with ICD-10-CM coding.
• Professional coder certification (AHIMA/AAPC: CPC‑a, RHIT, RHIA, CCA, CPC, COC, CPC‑P, CCS).
• Proficient in MS Excel and EMR systems.
• Strong Excel skills.
• Medical terminology knowledge.

• High School Diploma/GED or higher.
• Preferred 2+ years of post‑certification medical coding experience.
• Professional coder certification; valid certification  during interview/offer.
• 2+ years of experience in a PC in a Windows environment.

Work environment consists of daily patient contact, which may include exposure to blood or other body fluids.

Entry level

Full-time

Health Care Provider

Hospitals and Health Care