Medical Coder

General Responsibilities

Reporting to the Director of Revenue Cycle, the Medical Coder translates clinical documentation into standardized codes for billing, reporting, and quality initiatives. This role supports coding audits, revenue cycle workflows, and regulatory compliance. Key responsibilities include verifying clinical information with medical staff, resolving documentation gaps, and collaborating with billing staff to ensure accurate claims submission. The medical coder ensures appropriate codes are assigned to all procedures and diagnoses.

• Assigns and sequences of ICD-10-CM, CPT & HCPCS codes accurately in compliance with government and insurance regulations.
• Ensures codes reflect patient diagnoses and procedures as documented by clinicians, meeting payer, OSHA, and HIPAA requirements.
• Reviews and abstracts clinical documentation from outpatient encounters to assign accurate ICD-10-CM, CPT/HCPCS codes, and modifiers.
• Clarify and resolve coding questions or ambiguities for staff as needed.
• Gathers and compiles data from clinicians, EPIC, and other sources for monthly reporting.
• Collaborates with the Director of RQM to investigate reported medical malpractice by analyzing and identifying the medical procedures, diagnoses, or events that contributed to negligence.
• Validates coding accuracy through prospective and retrospective coding audits; implements corrective actions as needed.
• Collaborates with lead clinicians, clinicians, and other team members to resolve documentation gaps that affect coding accuracy and reimbursement.
• Maintains up-to-date knowledge of payer policies, CMS/Medicare updates, and specialty-specific coding practices (e.g., family practice, women’s health, etc.).
• Submits coded data to billing and medical records systems; verifies proper claim submission to ensure optimal reimbursement.

• 401(k)
• 401(k) matching
• Health insurance
• Paid time off
• Professional development assistance
• Vision insurance

• Associate (Required)

• Certified Medical Coding: 3 years (Required)

$33.09 - $40.62 an hour