Health Information Coder - Certified

The HIM Coder is responsible for ensuring the accuracy, integrity, and security of patient health information while supporting compliant coding and revenue cycle operations. This role assigns inpatient and outpatient diagnosis and procedure codes in accordance with ICD-10-CM Official Guidelines, internal policies, and applicable state regulations.

The position supports regulatory compliance, accurate reimbursement, and high-quality experiences for patients and providers by maintaining precise and timely medical record coding and safeguarding protected health information.

Medical Coding and Abstracting

• Assign codes for diagnoses, treatments, and procedures according to the appropriate classification system for inpatient, outpatient, and/or clinic encounters.
• Use coding principles and reimbursement expertise to assign ICD-10-CM diagnoses and procedures for inpatient and outpatient encounters.
• Assign present on admission (POA) values for inpatient diagnoses.
• Extract required information from source documentation and enter it into encoder and abstracting systems.
• Review provider documentation to determine principal diagnosis, co-morbidities, complications, secondary conditions, and surgical procedures.
• Note documentation deficiencies for completion by physicians or other professional staff.
• Abstract patient encounters using the appropriate software application.
• Assign appropriate codes for reimbursement purposes and to reflect severity of services.
• Identify chargeable items for emergency department, specialty clinic, outpatient, and series accounts and verify charges prior to abstracting outpatient encounters.

Clinical Documentation Improvement and Compliance

• Adhere to AHIMA Standards of Ethical Coding and all official coding guidelines and regulatory requirements.
• Monitor uncoded admission reports to ensure timely receipt, tracking, and processing of medical records.
• Support chart review processes to promote accuracy, completeness, and documentation integrity.

Revenue Cycle Management

• Review daily system-generated error reports and resolve issues identified through the billing scrub process.
• Validate and correct patient discharge disposition, admit type, and admit source based on supporting clinical documentation.
• Support process improvement initiatives that reduce downstream billing errors.

HIM Operations

• Assist with reviewing inpatient medical records for completeness in accordance with established documentation standards.
• Support tracking of medical records through the completion and reconciliation process.
• Assist with organizing inpatient medical records in the approved format for permanent filing.
• Perform additional duties as assigned to support departmental operations.