CODER/ABSTRACTOR (MEDICAL RECORDS) - (FT) Cody Regional Health · HEALTH INFORMATION MANAGEMENT
Cody , WY
Administrative Support
Full Time (80 pp) , Days
Posted 09/08/2026
JOB TITLE: Coder/Abstractor
DEPARTMENT: Health Information Management
REPORTS TO: Revenue Cycle Director
JOB SUMMARY
The purpose of this position is to apply the appropriate diagnostic and procedural codes to individual patient health information for data retrieval, analysis, and claims processing. Responsible for concurrently and retrospectively coding inpatient, outpatient (Observation) (Surgical Day Care), Emergency Department, physician clinic, hospitalist accounts, and ancillary medical records and abstracting information into the hospital information system. Will also be responsible with assisting other Revenue Cycle functions as needed.
JOB REQUIREMENTS
Minimum of successful completion of a coding certificate program in a program with AHIMA or AAPC approval status. Coding certification status preferred. Coding certification preferred from AAPC, American Health Information Management Association or the ability to sit for the examination within one year of employment. Prefer someone with work experience as a coder or strong training background in coding and reimbursement.
EXPERIENCE
Two years’ ICD and CPT coding experience and strong medical terminology knowledge preferred. One-year medical records abstracting experience preferred. Experience working in an acute care hospital or physician clinic working with networked computer system or 3M encoder and computer experience.
SKILLS
Knowledge of the revenue cycle, charge master, manual coding skills, encoder systems, and DNFB.
Thorough knowledge of CPT, current ICD coding system and HCPCS systems.
The ability to complete coding within pre-determined timeframe and accurately assign codes.
Must possess a high degree of confidentiality in all matters with the ability to manage sensitive and confidential situations with tact, professionalism, and diplomacy.
Must have strong interpersonal skills with the ability to communicate with staff and public in a friendly, courteous and helpful manner.
Display ability to work independently and to manage time well.
The ability to get along well with others.
Must have excellent organizational skills with the ability to multi-task.
Must have well-developed verbal and written communication skills.
Strong computer and keyboarding skills.
Must be proficient in the use of Microsoft Office Suite products knowledge including Word, Excel and Outlook.
Ability to learn new computer software applications.
Must know medical terminology.
Detail oriented.
REQUIRED CERTIFICATIONS
Coding certification preferred from AAPC, American Health Information Management Association or the ability to sit for the examination within one year of employment.
ESSENTIAL FUNCTIONS
Assist Utilization Review with concurrent coding of inpatient/outpatient medical records utilizing the ICD Code book.
Responsible for the final coding of all CRH physicians, hospital, CMC and LTCC medical records utilizing: ICD, CPT Code, and HCPCS coding books, the 3M encoder and the computer system.
Provides ongoing education and follow-up to physicians regarding E&M coding levels and medical necessity guidelines.
Identifies services and procedures provided but not adequately documented in the health record. Advises the department director of documentation deficiencies.
Identifies trends and ongoing problems related to medical documentation and recommends possible solutions.
Responsible for abstracting designated medical records information into the computer system (may include, but not be limited to, verifying that the discharge status is correct, name of anesthesiologist on surgical cases, referring and consulting physicians, blood and blood products codes, diagnosis codes, surgery date and type of anesthesia administered, and procedure codes).
Queries physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes.
Monitors unbilled accounts for outstanding or uncoded visits to reduce accounts receivable days for all patients.
Keeps abreast of coding guidelines and reimbursement reporting requirements. Brings identified concerns to thedirectorfor resolution.
Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.
Analyze records for Medical Staff quality indicators.
Maintains data, department activities, and all patient information in a confidential manner.
Consistently follows established procedures.
Assists with Revenue Cycle duties which include but are not limited to charge review, reporting, assisting CDI and organizational education.
Other duties as assigned.
SECONDARY FUNCTIONS
Attends all education set up by supervisor or department director as well as any other educational opportunities that benefit job performance.
Maintains coding credentials as well as continuing education hours.
Responsible for assisting with other Health Information Management Department functions, as requested.
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