Overview
Under minimal technical or managerial supervision, this position assigns codes to diagnoses and/or procedures using ICD10-CM and CPT-4 for observation, ambulatory surgeries, outpatient procedures, outpatient clinics and emergency room encounters. A Coder I will also research medical necessity needs if necessary and have a good working knowledge of Medicare Local Medical Review Policy (LMRPs)
Qualifications
Required Education:
High School Diploma or GED. Specific course work: Medical Terminology, Anatomy & Physiology, or other related course work
Preferred Education
Associate's or Bachelor's Degree in Health Information Management/Medical Record Administration. Equivalent healthcare college degree may also be considered.
Necessary Skills
• PC knowledge
• Good written and oral communication and customer service skills
• Must be detail oriented, organized and flexible
• Able to demonstrate initiative and perform minimum productivity levels
• Must have thorough knowledge of medical terminology, anatomy, and physiology and able to accept direction with changing priorities.
Preferred Licensure/Certifications
N/A
Required Experience
Six (6) months of acute care hospital outpatient coding experience.
Preferred Experience
At least one (1) year of experience coding emergency room and outpatient clinical records in a large acute care teaching facility.
Required Licensure/Certifications
Effective September 22, 2025 one of the certifications below is required at hire/transfer:
• RHIA/RHIT
• CCS
• CCA
• CPC-H
• CPC
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