Job Brief
The Health Information Coder is responsible for accurately compiling, processing, and maintaining comprehensive medical records for hospital and clinic patients. This role requires expertise in classifying medical diagnoses, procedures, services, and equipment using industry-standard coding systems. The ideal candidate will possess a strong understanding of medical terminology, coding guidelines, and regulatory requirements to ensure compliance with healthcare regulations. Proficiency in electronic health record (EHR) systems and a detail-oriented approach are essential for success in this position.
Responsibilities
- Compile and maintain accurate and up-to-date medical records for patients in accordance with ethical and legal standards.
- Classify medical diagnoses and procedures using the appropriate coding systems, such as ICD-10 and CPT.
- Review clinical documentation to ensure that all necessary information is captured for coding accuracy.
- Collaborate with healthcare professionals to clarify documentation discrepancies and optimize coding practices.
- Stay updated on the latest coding guidelines, regulations, and industry trends to ensure compliance and best practices.
- Utilize electronic health record (EHR) systems for efficient data entry and retrieval of patient information.
- Conduct audits and quality assurance checks on coded data to maintain coding accuracy and integrity.
- Facilitate training and support for new staff regarding coding procedures and ethical standards.
Requirements
- Certification as a Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or equivalent is preferred.
- Proven experience in medical coding and familiarity with medical terminology and healthcare regulations.
- Strong understanding of coding systems, including ICD-10, CPT, and HCPCS.
- Proficiency in using electronic health record (EHR) systems and medical coding software.
- Excellent attention to detail and the ability to work independently or as part of a team.
- Strong analytical skills and problem-solving capabilities.
- Effective communication skills, both written and verbal, to collaborate with healthcare staff.
- Knowledge of insurance billing processes and reimbursement methodologies is a plus.
Similar Job Titles
- Medical Coder
- Coding Specialist
- Healthcare Coder
- Revenue Cycle Coder
- Certified Medical Coder
- Clinical Coder
- Health Information Technician
- Billing and Coding Specialist
