Job Description: Medical Coder
Position: Medical Coder
Department: Healthcare and Medicine > Medicine
Reports to: Coding Manager
Job Summary:
The Medical Coder is responsible for accurately assigning medical codes to patient records, ensuring compliance with coding guidelines and regulations. This role plays a crucial part in maintaining accurate healthcare records and facilitating efficient billing processes. The Medical Coder is expected to possess a strong knowledge of medical terminology, coding systems, and relevant regulations, while maintaining a high level of attention to detail.
Key Responsibilities:
1. Accurately assign appropriate medical codes to patient records in adherence to established coding guidelines and regulations.
2. Review and analyze medical documentation, such as physician notes, operative reports, and laboratory results, to identify and extract relevant information for coding purposes.
3. Ensure accuracy and completeness of coded data, making necessary revisions or clarifications as required.
4. Collaborate with healthcare professionals to obtain additional information or clarification on coding-related matters.
5. Maintain proficiency in various coding systems, such as ICD-10-CM, CPT, and HCPCS, keeping up-to-date with any coding changes or updates.
6. Stay informed about relevant regulations and guidelines related to medical coding, including those set forth by government agencies and third-party payers.
7. Maintain a high level of confidentiality and adhere to all applicable privacy regulations when handling patient information.
8. Assist in the development and implementation of coding policies and procedures to ensure accuracy and consistency in coding practices.
9. Participate in coding audits and quality assurance activities to identify areas for improvement and ensure compliance with coding standards.
10. Collaborate with billing and revenue cycle teams to resolve coding-related issues and facilitate timely and accurate reimbursement.
Required Skills and Qualifications:
1. High school diploma or equivalent; coding certification (e.g., CPC, CCS-P) from a recognized program is required.
2. Minimum of [X] years of experience working as a Medical Coder in a healthcare setting.
3. In-depth knowledge of medical terminology, anatomy, physiology, and disease processes.
4. Proficiency in medical coding systems, including ICD-10-CM, CPT, and HCPCS.
5. Familiarity with coding guidelines and regulations, such as those set forth by CMS, AHIMA, and AAPC.
6. Excellent attention to detail and high level of accuracy in coding assignments.
7. Strong analytical and problem-solving skills to review and interpret complex medical documentation.
8. Ability to work independently and efficiently, managing multiple tasks and priorities.
9. Excellent communication and interpersonal skills to collaborate effectively with healthcare professionals, billing teams, and other stakeholders.
10. Solid understanding of privacy and confidentiality regulations (e.g., HIPAA) related to handling patient information.
Note: The above job description is intended to outline the general nature and level of work performed by the Medical Coder. It is not exhaustive and may be subject to change based on organizational needs.