Coder II

Under general supervision and according to established procedures, assigns codes to medical records. Codes patient medical records under ICD-10, CPT, HCPCS guidelines. Abstracts required data from documentation to support the coding. Enters ICD-10 and CPT codes in electronic medical record and finalizes accounts. Performs professional data entry. Researches information on claims that are denied, rejected, or encounters other issues.

• Analyzes patient medical records and interprets documentation to identify all diagnoses and procedures. Assigns proper ICD-10, CPT, and HCPCS codes.
• Applies sequencing guidelines to coded data according to official code rules.
• Data entry for professional coding.
• Works with providers to clarify medical record documentation and identifies issues that may need to be clarified.
• Answers questions regarding coding guidelines and assists other departments with coding and billing questions.
• Remains abreast of developments in medical records technology by attending webinars and educational programs.
• Meets minimum quality and productivity standards. Inpatient coders will send weekly productivity reports to supervisor.
• Acts as a resource for pre-authorization, patient registration, physician offices, and insurance companies calling with questions related to ICD or CPT codes.
• Review pertinent literature and keep up with current coding challenges.
• Maintains confidentiality of all hospital and patient information at all times. Follows HIPAA regulations and policies.
• Communicate with patients, physicians, families and co-workers in person or on the telephone.
• Provides professional customer service and responds in phone, personal, or electronic communication.
• Regular and predictable attendance is an essential job function.

• High school diploma or equivalent
• Coding certification: AAPC, RHIT, RHIA, CCS or CCS-P required
• 3 years’ experience required
• Demonstrated thorough knowledge of ICD coding conventions and CPT coding principles and meet the recommended AHIMA coding competencies
• Thorough knowledge of ICD/DRG coding optimization, and CPT coding principles including APC payment methodologies for outpatient hospital services is preferred
• Full time, 40 hours per week