Medical Records Coder-Associate

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.

• Proficiency in ICD-10 and CPT coding.
• Basic 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.

Education

• High school diploma or GED is required.

• Reviews, interprets, and assigns diagnostic and procedural codes based upon medical record documentation according to correct coding principles.
• Provides technical work in documentation and coding for medical billing, abstracts 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.
• Obtains medical records and charge fee information from patient care area.
• Contacts other facilities to obtain medical records and information needed to bill for services rendered.
• Verifies charge capture and physician notes for completeness to include abstracting and entering relevant medical information from the medical records; checks for required signatures; ensures proper documentation guidelines are followed.
• Codes diagnosis and procedures using classification coding systems.
• Reviews charge documents for completeness.
• Performs all other duties as assigned.