Medical Records Coder I, Full time - 8:30am-4:00pm, Family Medicine, Summit

Responsible for chart assembly, chart analysis, coding, and computer abstracting of all discharged patient medical records. Accurately assigns ICD-9-CM codes to all discharge diagnoses and processes requests for patient information. Makes decisions on codes and functions to be assigned in each instance including diagnostic and procedural information, significant reportable elements, and other complex classifications.


Principal Accountabilities:

Review clinical documentation and assign accurate ICD-10-CM, CPT, and HCPCS codes.

• Code office visits, procedures, and other services in accordance with payer requirements and organizational policies.
• Verify that documentation supports the codes and services billed; request clarification from clinicians when needed.
• Review charges before claim submission and correct coding errors or omissions.
• Research coding edits, claim rejections, and denials; make corrections and support appeals.
• Monitor coding work queues and complete assigned work within established timeframes.
• Stay current with coding updates, payer policies, and compliance requirements.
• Identify recurring documentation or coding issues and share guidance with clinicians and practice leadership.
• Maintain patient confidentiality and follow HIPAA requirements.

• Apply teaching physician and resident billing rules when reviewing services involving residents and supervising clinicians.

Level I - High School Diploma or equivalent. 0-3 years of experience in Physician coding, billing, or other related fields with demonstrated increased responsibility in the healthcare industry. CPC certification required, and Epic training preferred.