Position Summary: The Certified Medical Coder is responsible for reviewing patient medical records and accurately assigning diagnosis and procedure codes using ICD, CPT, and HCPCS classification systems. This role ensures compliance with regulatory guidelines, supports timely claims submission, and collaborates with clinical and billing staff to maintain coding accuracy and completeness.

Reports to: Coding Director

Supervisory responsibilities: None

Key Responsibilities include but not limited to:

• Assign accurate diagnosis and procedure codes using ICD-10-CM, CPT, and HCPCS systems
• Review and abstract medical record documentation, including chronic conditions and quality measures
• Ensure proper code sequencing in compliance with federal regulations and payer requirements
• Validate that documentation supports all coded diagnoses, procedures, and charges
• Identify and resolve documentation gaps; query providers for clarification when needed
• Research complex or unusual coding scenarios to ensure accuracy and compliance
• Collaborate with providers, clinical staff, and billing teams to resolve missing or incomplete charges
• Serve as a coding resource for providers and administrative staff
• Maintain compliance with coding guidelines, regulatory standards, and HIPAA requirements
• Meet established productivity and accuracy benchmarks
• Assist with onboarding, training, and mentoring of new staff as needed
• Perform additional duties as assigned

Knowledge, Skills & Abilities:

• Strong understanding of medical terminology, anatomy, and physiology
• Proficiency with Electronic Medical Records (EMR) systems and Microsoft Office Suite
• High attention to detail with strong analytical and problem-solving skills
• Excellent written and verbal communication skills
• Ability to manage multiple priorities and meet deadlines in a fast-paced environment
• Strong organizational skills and ability to work both independently and collaboratively
• Commitment to maintaining confidentiality and data integrity

Work Environment & Physical Requirements

• Primarily office-based setting, with possible remote capability with regular interaction with staff and providers
• Prolonged periods of sitting occasionally standing, bending, and stretching
• May occasionally lift up to 30 pounds
• Requires manual dexterity and visual acuity for computer-based work

Education

• High school diploma or equivalent required

Experience

• 1–2 years of medical coding experience or equivalent training/experience

Certifications (Required)

• One of the following active certifications:
• CPC or CRC (AAPC)
• CCS or CCS-P (AHIMA)
• RHIT (AHIMA)