Coder II

Key Responsibilities: 

Abstract Medical Records: Review and abstract medical record documentation from inpatient, outpatient, clinic, and emergency department settings. 

Code Selection: Accurately select and sequence ICD-10-CM/PCS, HCPCS, and CPT-4 codes based on the medical record documentation. 

Compliance Adherence: Follow coding compliance guidelines to ensure the assignment of complete, accurate, timely, and consistent codes for diagnoses and procedures. 

Final DRG Assignment: Assign the final Diagnosis Related Group (DRG) for inpatient cases, ensuring accurate grouping and coding. 

Documentation: Maintain detailed and accurate records of coding assignments and modifications, ensuring all coding decisions are well-supported by the documentation. 

Continuous Learning: Stay updated with current coding standards, regulations, and industry changes to ensure ongoing compliance and accuracy. 

Quality Assurance: Participate in quality assurance activities, including coding audits and reviews, to support continuous improvement in coding practices. 

Qualifications: 

• Must have one of the required credentials RHIA, RHIT, CCS or CPC.  

• Minimum of 1 years of coding experience in a hospital setting. 

• Proven experience in training or education, preferably in a healthcare environment. 

• Expertise in ICD-10-CM/PCS, HCPCS, and CPT4 coding systems. 

• Strong understanding of medical terminology, anatomy, physiology, and disease processes. 

• Excellent communication and interpersonal skills with the ability to effectively convey complex information to diverse audiences. 

• Detail-oriented with strong analytical and problem-solving skills. 

• Ability to work both independently and collaboratively within a team environment. 

• Proficiency in using electronic health record (EHR) systems and coding software.