Medical Records Coder-Senior

Under direct supervision, responsible for conducting review of inpatient and outpatient coding, assuring coding compliance with federal regulations, and maintains up-to-date coding guidelines and coding policy changes. Performs all tasks required to facilitate medical billing to include abstracting complex patient related data from medical records and coding of diagnoses and procedures using the ICD-10 and CPT classification systems.

This position will be a hybrid position working remote and/or on campus. Candidate being considered would need to live within commuting distance of UT Health San Antonio. Upon hire candidate will be required to be onsite for orientation and training. Transition to remote work is contingent on meeting productivity and quality standards as determined by supervisor. Remote Coders may be required to occasionally attend on campus training and meetings.

• Reviews, interprets, and assigns diagnostic and procedural codes based upon medical record documentation according to correct coding principles.
• Provides technical work in documentation and coding for medical billing, abstracts patient-related data from medical records and coding of diagnoses and procedures using ICD-10 and CPT codes.
• Works coding related charge review and claim edits daily to ensure timely and accurate billing.
• Obtains medical records and charge fee information from patient care area.
• Contacts other facilities to obtain medical records and information needed to bill for services rendered.
• Verifies charge capture and physician notes for completeness to include abstracting and entering relevant medical information from the medical records; checks for required signatures; ensures proper documentation guidelines are followed.
• Codes diagnosis and procedures using classification coding systems.
• Performs all other duties as assigned.

• Proficiency in ICD-10 and CPT coding.
• Basic understanding of medical terminology, anatomy and physiology.
• Meticulous attention to detail and accuracy.
• A solid customer service acumen and interpersonal skills to effectively work with both internal and external customers and responds to requests in a timely and respectful manner.
• Strong verbal, written and interpersonal communication skills.
• Accreditation from a professional coding organization, such as American Health Information Management Association (AHIMA), American Academy of Professional Coders (AAPC), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Specialist (CCS) certification is required.

EXPERIENCE:

• Five (5) years experience in medical record abstraction and coding is required.

CERTIFICATION:

• CBCS Certified Billing and Coding Specialist:
  National Health career Association Upon Hire Req Or
• RHIT Registered Health Information Technician:
  American Health Information Management Association (AHIMA), American Academy of Professional Coders (AAPC) Upon Hire Req Or
• RHIA Registered Health Information Administrator:
  American Health Information Management Association (AHIMA), American Academy of Professional Coders (AAPC) Upon Hire Req Or
• CCS Certified Coding Specialist:
  American Health Information Management Association (AHIMA), American Academy of Professional Coders (AAPC) Upon Hire Req Or
• CPC Certified Professional Coder American Academy of Professional Coders (AAPC). Upon Hire Req

• Five (5) years experience in medical record abstraction and coding is required.

• Job Identification 5883
• Job Category Clinical Programs & Services
• Posting Date 01/13/2026, 10:33 PM
• Locations  Fredericksburg Rd, San Antonio, TX, 78229, US (Hybrid)
• Apply Before 02/12/2026, 10:33 PM
• Degree Level HS Graduate or Equivalent
• Job Schedule Full time
• Job Shift 8am-5pm Mon-Fri
• Organization M3474 - UTHP Neurosurgery Coders, M3100 - UTHP UT Health Physicians, M1000 - Dean Medical School, UT Health Science Center, UT Health Science Center
• Department M3474 - UTHP Neurosurgery Coders