Job Summary
Health information coding is the transformation of verbal descriptions of diseases, injuries, and procedures into numeric or alphanumeric designations. Coders review and analyze health records to identify relevant diagnoses and procedures for patient encounters, translating diagnostic and procedural phrases into coded form to submit claims to payers for reimbursement. A collaborative effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.
Job Duties
Review the medical record content for hospital and professional inpatient or outpatient records to identify principal diagnoses, secondary diagnoses, and procedures, ensuring compliance with provider coding regulations.
Detail review of documents such as laboratory findings, radiology reports, scan reports, discharge summaries, history and physical, consultations, orders, progress notes, and other ancillary service records to record all pertinent diagnoses and procedures.
Translate diagnostic and procedural phrases into coded form using appropriate procedure codes.
Use encoder software to determine codes for all diagnoses and procedures.
Determine sequencing to legally maximize reimbursement.
Assign the appropriate DRG.
Apply hospital and professional coding guidelines, Coding Clinic directives, federal regulations, CCI coding initiatives, CPT Assistant, and other standard coding guidelines.
Query physicians as needed to clarify documentation within the patient’s record to facilitate complete and accurate coding.
Understand and apply internal policy and procedure guidelines for physician queries.
Assist the Coding Quality and Professional Manager with training new coding staff and reviewing coding guidelines annually, making recommendations for improvement.
Communicate new diagnoses, procedures, technologies, and related updates to the Coding Quality and Professional Manager.
Update and correct historical file data by completing and submitting claim action reports per the PHC4 quarterly report.
Work in conjunction with other revenue cycle and external departments to ensure coordinated activities.
Certification Requirements
One relevant certification from AHIMA or AAPC is required upon hire. Acceptable certifications include:
AHIMA: Certified Coding Specialist (CCS), Certified Coding Specialist – Physician-based (CCS‑P), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Associate (CCA) – those with only a CCA must obtain a CCS, RHIT, or RHIA within 12 months of hire.
AAPC: All certifications are acceptable except Scribe, Documentation, Instructor, International Credentials, Certified Professional Biller (CPB), Revenue Cycle Management Specialist (RCMS), Certified Value-Based Administrator (CVBA), Certified Physician Practice Manager (CPPM), Certified Professional Compliance Officer (CPCO).
Education
High School Diploma or Equivalent (GED) – Required. Graduate from a specialty training program – Preferred.
Experience
Minimum of 1 year of related work experience – Required.
Benefits
Full‑time and part‑time positions receive healthcare benefits from day one, including vision and dental coverage, and domestic partner benefits.
Equal Opportunity
We are proud to be an affirmative action, equal opportunity employer. All qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
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