Coder/Sr. Medical Coder

reviews healthcare documentation and translates it into standardized codes for billing, insurance reimbursement, and data analysis

Core Responsibilities:

• Reviewing Medical Records:

  Analyzing patient charts, physician's notes, lab reports, and other documentation to understand the services provided.

• Assigning Codes:

  Applying appropriate codes from systems like ICD-10, CPT, and HCPCS to represent diagnoses, procedures, and services.

• Ensuring Accuracy and Compliance:

  Following coding guidelines and regulations to ensure correct code assignment and compliance with payer requirements.

• Collaborating with Others:

  Working with physicians, nurses, and billing staff to clarify documentation and resolve coding issues.

• Maintaining Records:

  Ensuring accurate and complete patient records through proper coding and documentation.

• Staying Updated:

  Keeping current with changes in coding guidelines, regulations, and healthcare technology.

• Claim Support:

  Supporting the billing process by providing accurate coding information.

• Data Analysis:

  Contributing to data collection and analysis for research, quality improvement, and public health reporting.

Skills and Qualifications:

• Medical Terminology and Anatomy:

  A strong understanding of medical terminology and human anatomy is crucial.

• Coding Systems:

  Proficiency in ICD-10, CPT, and HCPCS coding systems.

• Attention to Detail:

  Accuracy is paramount in medical coding to ensure proper billing and reimbursement.

• Analytical Skills:

  The ability to analyze medical records and identify relevant information for coding.

• Communication Skills:

  Effective communication with healthcare providers and other team members.

• Problem-Solving Skills:

  The ability to resolve coding discrepancies and address claim issues.

• Certification:

  Many employers require or prefer certification from organizations like AAPC or AHIMA.