HIM Tech; Non-Cert

Overview

The Staff Pad has partnered with a hospital in Las Vegas, New Mexico to recruit an experienced Health Information Management (HIM) Coder to join their on-site team. This individual will be responsible for reviewing, analyzing, and assigning diagnostic and procedural codes for inpatient, outpatient, and/or emergency department medical records using ICD-10-CM, CPT, and HCPCS coding systems in accordance with official coding guidelines and facility standards.

• Review and abstract clinical documentation from patient records to assign accurate diagnosis and procedure codes
• Ensure compliance with federal regulations and hospital policies related to coding and billing
• Maintain productivity and quality standards established by the HIM department
• Query physicians when appropriate to ensure accurate and complete documentation
• Assist in resolving coding-related billing issues or discrepancies
• Stay current with coding guidelines, payer regulations, and industry best practices
• Participate in internal audits and ongoing education for coding accuracy and compliance
• Communicate effectively with physicians, clinical staff, and HIM leadership

• High school diploma or equivalent required
• Associate degree in Health Information Technology or related field preferred
• Minimum of 2 years of experience in a healthcare coding role
• Strong understanding of ICD-10-CM, CPT, and HCPCS coding systems
• Knowledge of CMS guidelines and medical terminology
• Familiarity with electronic health record (EHR) systems
• Strong attention to detail and organizational skills

This is an on-site position based in Las Vegas, NM, working in a professional hospital or clinical office setting with standard business hours and adherence to HIPAA compliance and facility policies.