Coder I

Major Responsibilities:

• Assigns codes based on clinical documentation to office-based visits including procedures utilizing International Classification of Diseases (ICD), Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS).
• Adheres to the organization and departmental guidelines, policies and protocols.
• Sequences diagnoses and procedure codes as outlined in CPT, ICD and HCPCS Coding Guidelines while adhering to local and national governmental payer guidelines.
• Reviews all clinician documentation to support assigned codes in the health information record so that all significant diagnoses and procedures may be captured for reimbursement and data purposes.
• Follow up and obtain clarification of inaccurate documentation as appropriate.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines. Practices ethical judgment in assigning and sequencing codes for proper insurance reimbursement.
• Maintains the confidentiality of patient records. Reports any perceived non-compliant practices to the coding leader or compliance officer.
• Metrics: Meets then exceeds departmental quality and productivity standards.
• Responsible for processing Coding Claim Denials and Coding Claim Rejections, when applicable.

Licensure, Registration, and/or Certification Required:

• Coding Certification issued by one of the following certifying bodies: American Academy of Coders (AAPC), or American Health Information Management Association (AHIMA)

Education Required:

• Advanced training beyond High School in Medical Coding (or equivalent knowledge)

Experience Required:

• Typically requires 1 year of related experience

Knowledge, Skills & Abilities Required:

• Knowledge of ICD, CPT and HCPCS coding guidelines. Knowledge of medical terminology, anatomy and physiology.
• Basic computer skills including the use of Microsoft office products, electronic mail, including exposure or experience with electronic coding systems or applications.
• Basic communication (oral and written) and interpersonal skills.
• Basic organization, prioritization, and reading comprehension skills.
• Basic analytical skills, with a high attention to detail. 
• Ability to work independently and exercise independent judgment and decision making.
• Ability to meet deadlines while working in a fast-paced environment.
• Ability to take initiative and work collaboratively with others.

Physical Requirements and Working Conditions:

• Exposed to a normal office environment.
• Must be able to sit for extended periods of time.
• Must be able to continuously concentrate.
• Position may be required to travel to other sites; therefore, may be exposed to road and weather hazards.
• Operates all equipment necessary to perform the job.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.