Full job description

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Medical Records Coder will be responsible for reviewing, interpreting and abstracting clinical information from medical records for the purposes of reimbursement, research, and compliance, adhering to coding guidelines and processing as per established productivity standards for all accounts assigned. He/she checks and distributes reports and files inpatient records while maintaining patient confidentiality.

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Roles and Responsibilities

Ensure appropriate selection of principal diagnosis, qualifying secondary diagnosis, impacting procedures and other services which is relevant for submission and reimbursement.

Effective physician query process prior to code assignment to obtain the greatest possible diagnostic specificity and clinical documentation to accurately reflect the patient's condition.

Consistently maintain quality and productivity standards and achieve the productivity target and quality targets

Ensures to reduce rejections and get the claim paid at the initial submission of claims.

Perform other related duties incidental to the work described herein.

Identify documentation deficiencies and query physicians for clarification and additional documentation prior to code assignment.

Adhere to the coding guidelines

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Education, Experience, and skills needed

Education: Degree in any related field preferably medical or life science background. CCS (AHIMA) or CPC (AAPC) certification is mandatory.

Minimum of one-two (1-2) years coding experience in any setting. Both inpatient and outpatient experience preferred.

Willingness to work in different shifts

Willingness to work from different facility

Good skill in assigning accurate CPT, ICD-10-CM, DRG, HCPCS and other service codes for diagnosis and procedures performed in the OP/ER/IP setting

Proficiency in medical terminology, anatomy and physiology

Excellent in communication skills.

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