Senior Medical Records Coder

Under direct supervision, responsible for conducting review of inpatient and outpatient coding, assuring coding compliance with federal regulations, and maintains up-to-date coding guidelines and coding policy changes. Performs all tasks required to facilitate medical billing to include abstracting complex patient related data from medical records and coding of diagnoses and procedures using the ICD-10 and CPT classification systems.

This position will be a hybrid position working remote and/or on campus. Candidate being considered would need to live within commuting distance of UT Health San Antonio. Upon hire candidate will be required to be onsite for orientation and training. Transition to remote work is contingent on meeting productivity and quality standards as determined by supervisor. Remote Coders may be required to occasionally attend on campus training and meetings. 

Proficiency in ICD-10 and CPT coding. In-depth understanding of medical terminology, anatomy and physiology. Meticulous attention to detail and accuracy. A solid customer service acumen and interpersonal skills to effectively work with both internal and external customers and responds to requests in a timely and respectful manner. Strong verbal, written and interpersonal communication skills.

Reviews, interprets, and assigns diagnostic and procedural codes based upon medical record documentation according to correct coding principles. Provides skilled and specialized technical work in documentation and coding for medical billing, abstracts complex patient-related data from medical records and coding of diagnoses and procedures using ICD-10 and CPT codes. Works coding related charge review and claim edits daily to ensure timely and accurate billing. Researches and resolves coding related issues, and assists in meeting productivity and quality standards. Contacts other facilities to obtain medical records and information need to bill for services rendered. Verifies fee tickets and physician notes for completeness to include abstracting and entering relevant medical information from the medical records; checks for required signatures; assures proper documentation guidelines are followed. Interacts with regulator classification agencies and patients when clarification and additional information is required for documentation. Reviews charge documents for completeness. Updates coding books with changes as accepted and published by regulatory agencies. Performs all other duties as assigned.