Medical record coder job description
Updated March 14, 2024
7 min read
Find better candidates in less time
Post a job on Zippia and take the best from over 7 million monthly job seekers.
Example medical record coder requirements on a job description
Medical record coder requirements can be divided into technical requirements and required soft skills. The lists below show the most common requirements included in medical record coder job postings.
Sample medical record coder requirements
- Proficient in ICD-10-CM and CPT coding systems
- Knowledge of medical terminology and anatomy
- Ability to read, analyze and interpret medical records
- Attention to detail and accuracy
- Associate's degree in Health Information Management or related field
Sample required medical record coder soft skills
- Excellent communication skills
- Ability to work independently and in a team environment
- Strong analytical and problem-solving skills
- Adaptability and flexibility in a fast-paced environment
- Commitment to maintaining patient confidentiality
Medical record coder job description example 1
Atrium Health Floyd medical record coder job description
Reviews clinical documentation and diagnostic results as appropriate to abstract data and apply appropriate ICD-9-CM/ICD-10-CM/PCS1 and CPT 4 codes for reimbursement, external reporting, research, regulatory compliance, medical necessity, CCI, NCCI and other regulatory edits. Code and abstract medical records of moderate to high complexity within the Primary Enterprise acute care facilities.
Essential Functions
Reviews moderate to high complexity medical records to identify the appropriate principal diagnosis and procedure codes and all other appropriate secondary diagnoses and procedure codes and assign Present on Admission indicators, Hospital Acquired Conditions and Core Measures for all diagnosis codes. Facilitates appropriate MSDRG for inpatient medical records and appropriate APC assignment for outpatient medical records using UHDDS and other facility guidelines. Reviews charges and Evaluation and Management levels. Demonstrates the technical competence to use the facility encoder as it interfaces with the hospital mainframe and/or EMR in an on-site or remote setting. Abstracts coded data and other pertinent fields in the hospital electronic health record. Ensures the accuracy of data input. Meets established quality and productivity standards. Stay abreast of coding principles and regulatory guidelines related to inpatient and/or outpatient coding.
Physical Requirements
Must be able to concentrate and sit for long periods of time while reviewing electronic health records. Daily and weekly deadlines must be met in a fast paced office environment and/or at home environment.
Education, Experience and Certifications.
High School Diploma or GED required; Bachelor's Degree preferred. Advanced knowledge in Medical Terminology, Anatomy and Physiology and Pharmacology required. 2 years coding experience in acute care setting required. Current RHIT, RHIA, CPC-H, CIC or CCS required plus a passing score on the Coding test.
About Us
Atrium Health is one of the nation's leading healthcare organizations, connecting patients with on-demand care, world-class specialists and the region's largest primary care network. A recognized leader in healthcare delivery, quality and innovation, our foundation rests on providing clinically excellent and compassionate care.
We've been serving our community since 1940, when we opened our doors as Charlotte Memorial Hospital. Since then, our network has grown to include more than 40 hospitals and 900 care locations ranging from doctors' offices to behavioral health centers to nursing homes.
Our focus: Delivering the highest quality patient care, supporting medical research and education, and joining with partners outside our walls to keep our community healthy.
About the Team
Our Mission Statement, Vision and Values
Our Mission: To improve health, elevate hope and advance healing - for all.
Our Vision: To be the first and best choice for care.
Our Values: We recognize that employees are our most valuable asset. We have identified four core values we hold in the highest regard: caring, commitment, integrity and teamwork.
Essential Functions
Reviews moderate to high complexity medical records to identify the appropriate principal diagnosis and procedure codes and all other appropriate secondary diagnoses and procedure codes and assign Present on Admission indicators, Hospital Acquired Conditions and Core Measures for all diagnosis codes. Facilitates appropriate MSDRG for inpatient medical records and appropriate APC assignment for outpatient medical records using UHDDS and other facility guidelines. Reviews charges and Evaluation and Management levels. Demonstrates the technical competence to use the facility encoder as it interfaces with the hospital mainframe and/or EMR in an on-site or remote setting. Abstracts coded data and other pertinent fields in the hospital electronic health record. Ensures the accuracy of data input. Meets established quality and productivity standards. Stay abreast of coding principles and regulatory guidelines related to inpatient and/or outpatient coding.
Physical Requirements
Must be able to concentrate and sit for long periods of time while reviewing electronic health records. Daily and weekly deadlines must be met in a fast paced office environment and/or at home environment.
Education, Experience and Certifications.
High School Diploma or GED required; Bachelor's Degree preferred. Advanced knowledge in Medical Terminology, Anatomy and Physiology and Pharmacology required. 2 years coding experience in acute care setting required. Current RHIT, RHIA, CPC-H, CIC or CCS required plus a passing score on the Coding test.
About Us
Atrium Health is one of the nation's leading healthcare organizations, connecting patients with on-demand care, world-class specialists and the region's largest primary care network. A recognized leader in healthcare delivery, quality and innovation, our foundation rests on providing clinically excellent and compassionate care.
We've been serving our community since 1940, when we opened our doors as Charlotte Memorial Hospital. Since then, our network has grown to include more than 40 hospitals and 900 care locations ranging from doctors' offices to behavioral health centers to nursing homes.
Our focus: Delivering the highest quality patient care, supporting medical research and education, and joining with partners outside our walls to keep our community healthy.
About the Team
Our Mission Statement, Vision and Values
Our Mission: To improve health, elevate hope and advance healing - for all.
Our Vision: To be the first and best choice for care.
Our Values: We recognize that employees are our most valuable asset. We have identified four core values we hold in the highest regard: caring, commitment, integrity and teamwork.
Post a job for free, promote it for a fee
Medical record coder job description example 2
BayCare Health System medical record coder job description
Title: Medical Records Coder II
Location: Florida
BayCare is currently in search of our newest Team Member who is passionate about providing outstanding customer service to our community. We are looking for an individual seeking a career opportunity with one of the largest employers within the Tampa Bay area.
The **Medical Records Coder II** will work remote on a PRN as needed basis. This team member must reside in FL. The Medical Records Coder II must have 2 years of Coding experience. This postion requires a CCS (Coding).
**Responsibilities**
+ The Medical Records Coder II assigns diagnosis and procedural codes using ICD-10-CM, ICD-10-PCS, and CPT-4 coding systems and monitors bill hold reports.
+ Assists Manager. Director with mentoring/training of Coder I team members and clinical practice students from various colleges. Performs other duties as assigned.
**Specific Skills**
+ Critical thinking skills
+ Organizational skills
+ Written and verbal communication skills
+ Customer service skills
+ Computer skills appropriate to position
+ Knowledge of regulatory standards appropriate to position
+ Medical terminology use and understanding
**Why BayCare?**
Our network consists of 15 community-based hospitals, a long-term acute care facility, home health services, outpatient centers and thousands of physicians. With the support of more than 30,000 team members, we promote a forward-thinking philosophy that is built on a foundation of trust, dignity, respect, responsibility, and clinical excellence. Our team members focus on tomorrow by achieving personal and professional success today. That is why you will thrive in our forward-thinking culture, where we combine the best technology with compassionate service. We blend high-tech with high touch in ways that are advancing superior health care throughout the communities we serve.
Qualifications:
**Certifications and Licensures**
+ Preferred CCS (Coding)
+ Preferred RHIT (Health Information
**Education**
+ Required High School or equivalent
+ Preferred Associates Degree Health Information Technology
**Experience**
+ Required 2 years Coding
Schedule: Monday, Tuesday, Wednesday, Thursday, Friday
Shift: Days
Shift Hours: 7:30AM - 4:30PM
Weekend Work: Occasional
On Call: No
Employment Status: ACTIVE PRN
Equal Opportunity Employer Veterans/Disabled
Location: Florida
BayCare is currently in search of our newest Team Member who is passionate about providing outstanding customer service to our community. We are looking for an individual seeking a career opportunity with one of the largest employers within the Tampa Bay area.
The **Medical Records Coder II** will work remote on a PRN as needed basis. This team member must reside in FL. The Medical Records Coder II must have 2 years of Coding experience. This postion requires a CCS (Coding).
**Responsibilities**
+ The Medical Records Coder II assigns diagnosis and procedural codes using ICD-10-CM, ICD-10-PCS, and CPT-4 coding systems and monitors bill hold reports.
+ Assists Manager. Director with mentoring/training of Coder I team members and clinical practice students from various colleges. Performs other duties as assigned.
**Specific Skills**
+ Critical thinking skills
+ Organizational skills
+ Written and verbal communication skills
+ Customer service skills
+ Computer skills appropriate to position
+ Knowledge of regulatory standards appropriate to position
+ Medical terminology use and understanding
**Why BayCare?**
Our network consists of 15 community-based hospitals, a long-term acute care facility, home health services, outpatient centers and thousands of physicians. With the support of more than 30,000 team members, we promote a forward-thinking philosophy that is built on a foundation of trust, dignity, respect, responsibility, and clinical excellence. Our team members focus on tomorrow by achieving personal and professional success today. That is why you will thrive in our forward-thinking culture, where we combine the best technology with compassionate service. We blend high-tech with high touch in ways that are advancing superior health care throughout the communities we serve.
Qualifications:
**Certifications and Licensures**
+ Preferred CCS (Coding)
+ Preferred RHIT (Health Information
**Education**
+ Required High School or equivalent
+ Preferred Associates Degree Health Information Technology
**Experience**
+ Required 2 years Coding
Schedule: Monday, Tuesday, Wednesday, Thursday, Friday
Shift: Days
Shift Hours: 7:30AM - 4:30PM
Weekend Work: Occasional
On Call: No
Employment Status: ACTIVE PRN
Equal Opportunity Employer Veterans/Disabled
Dealing with hard-to-fill positions? Let us help.
Medical record coder job description example 3
Acadia Healthcare medical record coder job description
+ Assign appropriate codes using International Classification of Disease system (ICD-10) and/or Current Procedural Terminology (CPT) for diagnosis, procedures and services.
+ Responsible for correctly coding claims based on the services a patient receives in order to obtain reimbursement from insurance or government healthcare programs.
+ Read and analyze patient records extracting precise information from documentation, test results and reports.
+ Request diagnosis from physicians when not recorded on discharge and in cases where information is incomplete.
+ Maintain confidentiality regarding patient care information and chart contents.
+ Inform administrator of any incongruences noted in the chart record.
+ When appropriate clarify diagnosis, conditions and treatment information by working with the physician according to company policy and procedure.
+ Process physician reports needed to code appropriately and accurately.
+ Organize and analyze medical records for accuracy and completeness.
+ Pull charts as requested for audits, peer review, readmissions, HBIPS processing and route to appropriate area or department.
+ Ensure files are stored in the designated area according to storage procedures.
+ Maintain and search computerized medical records.
+ Maintain chart control, access and storage in accordance with established policies, procedures and regulations.
+ Assist with HIM department audits including HBIPS, CMS Quality Measures, and concurrent reviews.
+ Pick up discharge records from patient units.
+ Print and deliver medical records forms to patient units.
+ Search and print dictated reports from computerized transcription system.
Qualifications
Skills
Required
+ Safety Minded: Novice
+ Oral Communication: Novice
+ Planning & Organizing: Novice
+ Financial Awareness: Novice
+ Attention to Detail: Novice
Behaviors
Required
+ Detail Oriented: Capable of carrying out a given task with all details necessary to get the task done well
+ Team Player: Works well as a member of a group
Motivations
Required
+ Self-Starter: Inspired to perform without outside help
+ Goal Completion: Inspired to perform well by the completion of tasks
Preferred
+ Job Security: Inspired to perform well by the knowledge that your job is safe
Education
Required
+ High School/GED or better
Licenses & Certifications
Required
+ Cert Coder
Experience
Preferred
+ 2 years: Coding
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)
+ Responsible for correctly coding claims based on the services a patient receives in order to obtain reimbursement from insurance or government healthcare programs.
+ Read and analyze patient records extracting precise information from documentation, test results and reports.
+ Request diagnosis from physicians when not recorded on discharge and in cases where information is incomplete.
+ Maintain confidentiality regarding patient care information and chart contents.
+ Inform administrator of any incongruences noted in the chart record.
+ When appropriate clarify diagnosis, conditions and treatment information by working with the physician according to company policy and procedure.
+ Process physician reports needed to code appropriately and accurately.
+ Organize and analyze medical records for accuracy and completeness.
+ Pull charts as requested for audits, peer review, readmissions, HBIPS processing and route to appropriate area or department.
+ Ensure files are stored in the designated area according to storage procedures.
+ Maintain and search computerized medical records.
+ Maintain chart control, access and storage in accordance with established policies, procedures and regulations.
+ Assist with HIM department audits including HBIPS, CMS Quality Measures, and concurrent reviews.
+ Pick up discharge records from patient units.
+ Print and deliver medical records forms to patient units.
+ Search and print dictated reports from computerized transcription system.
Qualifications
Skills
Required
+ Safety Minded: Novice
+ Oral Communication: Novice
+ Planning & Organizing: Novice
+ Financial Awareness: Novice
+ Attention to Detail: Novice
Behaviors
Required
+ Detail Oriented: Capable of carrying out a given task with all details necessary to get the task done well
+ Team Player: Works well as a member of a group
Motivations
Required
+ Self-Starter: Inspired to perform without outside help
+ Goal Completion: Inspired to perform well by the completion of tasks
Preferred
+ Job Security: Inspired to perform well by the knowledge that your job is safe
Education
Required
+ High School/GED or better
Licenses & Certifications
Required
+ Cert Coder
Experience
Preferred
+ 2 years: Coding
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)
Start connecting with qualified job seekers
Resources for employers posting medical record coder jobs
Average cost of hiring
Recruitment statistics
How to write a job description
Examples of work conditions
Medical record coder job description FAQs
Ready to start hiring?
Updated March 14, 2024
Updated March 14, 2024