Medical Records Coder-Senior

Job Description

Under direct supervision, responsible for conducting review of inpatient and outpatient coding, ensuring coding compliance with federal regulations, and maintaining 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 is a hybrid role working remotely and/or on campus. Candidates must live within commuting distance of UT Health San Antonio. Upon hire, the 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 the supervisor. Remote coders may be required to attend occasional on‑campus training and meetings.

• Reviews, interprets, and assigns diagnostic and procedural codes based on 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 codes 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, abstracts and enters relevant medical information from the records, checks for required signatures, and ensures proper documentation guidelines are followed.
• Codes diagnoses and procedures using classification coding systems.
• Reviews charge documents for completeness.
• 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.
• Strong customer service acumen and interpersonal skills to work effectively with internal and external customers and respond to requests in a timely and respectful manner.
• Strong verbal, written, and interpersonal communication skills.
• Accreditation from a professional coding organization such as AHIMA, AAPC, RHIT, RHIA, or a certified coding specialist (CCS) certification is required.

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

• CBCS Certified Billing and Coding Specialist:
  National Health Career Association.
• RHIT Registered Health Information Technician: AHIMA or AAPC.
• RHIA Registered Health Information Administrator: AHIMA or AAPC.
• CCS Certified Coding Specialist: AHIMA or AAPC.
• CPC Certified Professional Coder: AAPC.

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