Job Title: Medical Coder

Department: CBO (Administrative) – Non-exempt

Reports To: Director of Revenue Cycle

Position Summary

This position will provide quality review and analysis of a wide range of patient medical records and ensure accuracy of coding and maintain records in accordance with accepted medical and legal standards. Responsible for reviewing medical records to assure proper billing of the medical record, comparison of physician chosen CPT and ICD-10 codes to the physicians' documentation to substantiate the level of coding, physician services to include identification of professional services in and complete review of medical records to accurately optimize all professional services documented for billing.

Essential Duties & Responsibilities

• Assign codes to diagnoses and procedures, using ICD (International Classification of Diseases) and CPT (Current Procedural Terminology) codes

• Ensure codes are accurate and sequenced correctly in accordance with government and insurance regulations

• Analyze medical record documentation for consistency and completeness for coding purposes using established criteria and regulations

• Follow up with the provider on any documentation that is insufficient or unclear

• Communicate with other clinical staff regarding documentation

• Search for information in cases where the coding is complex or unusual

• Receive and review patient charts and documents for accuracy

• Review the previous day's batch of patient notes for evaluation and coding

• Ensure that all codes are current and active

• Perform other duties as assigned

Qualifications

EDUCATION AND EXPERIENCE

• High school diploma, GED, or equivalent

• University/college degree, or experience medical records, claims or billing areas is an asset.

• Previous medical office experience preferred.

• Strong knowledge of anatomy, physiology and medical terminology

• Excellent typing and 10-key speed and accuracy

• Commitment to a high level of customer service

• Superior mathematical skills

• Familiarity with ICD-9 codes and procedures

• Solid oral and written communication skills

• Working knowledge of medical jargon and anatomy preferred

• Able to work independently

Knowledge, Skills, Abilities

• Problem Solving – Ability to identify a problem and find solutions effectively

• Safety and Confidentiality - Follows OSHA regulations and the safety guidelines of the Practice. Follows HIPAA policies and procedures. Respects and maintains patient confidentiality. 

• Organization — Uses time efficiently by prioritizing and planning work activities; is methodical and efficient in structuring tasks to be accomplished.

• Professional Maturity — The ability to separate emotional feelings from the real issues at hand. The ability to legitimately and objectively challenge the substance of our beliefs and biases of our observations.

• Time Management — Managing one's own time and the time of others; the ability to shift back and forth between two or more activities or sources of information (such as speech, sounds, touch, or other sources).

• Active Listening — Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.

• Interpersonal Communication — Writes and speaks effectively based on the psychological, relational, situation, environmental and cultural dynamics within the situation 

• Communication — The ability to write and speak effectively using appropriate convention based on the situation; actively listens to others, asks questions to verify understanding, and uses tact and consideration when delivering feedback to others.   

Physical Demands

• Physical Demands: Substantial movements (motion) of the wrist, hands, and/or fingers in a repetitive manner. 

Work Environment

• Well-lighted, heated and/or air-conditioned indoor clinic office setting with adequate ventilation; Moderate noise (examples: business office with computers and printers, light traffic) Typical schedule is Monday through Friday with regular working hours; travel to clinics may be required.