Job Description

About the Role

The Health Information Management (HIM) Coder is responsible for ensuring accuracy, integrity, and security of patient health information while supporting compliant coding and revenue cycle operations. The coder assigns inpatient and outpatient diagnosis and procedure codes in accordance with the annual updated ICD-10-CM Official Guidelines for Coding and Reporting, as published by CMS and NCHA, as well as applicable internal policies and state regulations. By maintaining precise and timely medical record coding and safeguarding protected health information, the HIM Coder contributions to regulatory compliance, accurate reimbursement, and high-quality experience for patients and providers.

How You’ll Make an Impact

As a HIM Coder, you ensure the accuracy, integrity, and security of patient health information by assigning compliant inpatient and outpatient diagnosis and procedure codes in accordance with ICD-10-CM Official Guidelines, internal policies, and applicable regulations. You play a key role in protecting patient data, supporting accurate reimbursement, and maintaining revenue cycle integrity. Your work directly impacts data quality, regulatory compliance, and the overall patient and provider experience.

Medical Coding and Abstracting

· Assigns codes for diagnoses, treatments, and procedures according to the appropriate classification system for inpatient, outpatient, and/or clinic encounters.

· Utilizes technical coding principles and MS-DRG reimbursement expertise to assign appropriate ICD-10-CM diagnoses and procedures on inpatient encounters.

· Utilizes technical coding principles and APC reimbursement expertise to assign appropriate ICD-10-CM diagnoses and CPT/HCPCS procedures on outpatient and/or clinic encounters.

· Assigns present on admission (POA) value for inpatient diagnoses.

· Extracts required information from source documentation and enters into encoder and abstracting system.

· Reviews appropriate provider documentation to determine principal diagnosis, co-morbidities and complications, secondary conditions and surgical procedures.

· Notes deficiencies to be completed by physicians or other professional staff.

· Abstracts all patient encounters using the appropriate software application.

· Assigns appropriate codes for reimbursement purposes and to reflect the severity of services.

· Identifies chargeable items for emergency department, specialty clinic visits, medical outpatient and series accounts and verifies appropriate charges are present prior to abstracting outpatient encounters.

Clinical Documentation Improvement and Compliance

• Adheres to the AHIMA Standards of Ethical Coding and complies with all official coding guidelines and regulatory requirements.
• Monitors uncoded admission reports to ensure timely receipt, tracking, and processing of all medical records.
• Supports chart review processes to promote accuracy, completeness, and documentation integrity.

Revenue Cycle Management

• Reviews daily system-generated error reports and resolves issues identified through the billing scrub process.
• Validates and corrects patient discharge disposition, admit type, and admit source bases on supporting clinical documentation.
• Supports initiatives to identify and implement process improvements that reduce downstream billing errors.

HIM Operations

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

Requirements

Qualifications

• High school diploma or equivalent preferred.
• Associate of Science degree in Health Information Management or related field preferred.
• Completion of coursework in anatomy and physiology, with foundational knowledge of pharmacology, anatomy, and disease processes.
• Successful completion of AHIMA CCA or CCS certification, AAPC certification, or COC exam.
• Successful completion of AAPC CASCC or CGSC or CANPC.
• Two years of direct coding experience and completion of a certified program (RHIT, CPC, CCS, or CCA through AHIMA, or COC-H through AAPC).

Who You Are

• Detail oriented with a strong commitment to accuracy in documentation and data integrity.
• Reliable team member who upholds confidentiality, structure, and consistency in all work.
• Adaptable and eager to learn new systems, standards, and processes.
• Professional, patient, and effective when collaborating with diverse teams and responding to information requests.
• Self motivated and proactive, with the ability to manage tasks independently and meet deadlines with minimal supervision.

Skills and Capabilities

• Strong understanding of health information workflows, documentation standards, and medical terminology.
• Ability to interpret, compile, and analyze statistical data with a high level of accuracy and attention to detail.
• Proficiency in Windows-base systems, Microsoft applications, scanning systems, and data entry tools.
• Strong written and verbal communication skills.
• Ability to manage multiple priorities, meet deadlines, and maintain accuracy in a fast-paced environment.
• Knowledge of HIPAA requirements, confidentiality standards, and release of information processes.

Position Details

Schedule: Full time, non exempt; 40 hours/week with regular and punctual attendance required.

Physical Requirements: Primarily seated computer work with some walking, bending, stooping, and lifting up to 25 lbs. Must be able to read, write, hear, and comprehend written material.

Equipment: Standard office equipment; computer/printer; scanner; 10 key; fax/phone; copy machine.

Acknowledgment

I acknowledge that I have reviewed and understand the contents of this job description. I understand that this document may be revised at the organization’s discretion and does not constitute a contract of employment. Employment is at will and may be changed with or without notice, including but not limited to duties, location, compensation, benefits, or employment status.