Clinic Coder

Job description

Job Title: Coder Department: Health Information Management (HIM): Reports to: HIM Manager: FLSA Status: Non-Exempt: Overall Responsibility: The Coder, under the general direction of the Manager of HIM, is primarily responsible for reviewing medical record documentation and assigning accurate diagnosis and procedure codes. Performs analysis of medical records. Audits medical records for completeness and proper documentation. Assists business office with coding issues. Key tasks and responsibilities: Essential functions: - Codes and abstracts medical records using ICD-10-CM and ICD-10-PCS and CPT codes. - Assists Billers regarding coding issues and questions. - Assists with responses to KFMC (the QIO) and other review organizations. - Communicates routinely with physicians about diagnoses, procedures, and documentation. - Queries physicians and other healthcare providers when code assignments are not straightforward or documentation is inadequate, ambiguous, or unclear for coding and legal health purposes. - Audits medical records for completeness and accurate information. - Maintains knowledge of current state and federal coding guidelines. - Analyzes records for physician deficienc...