Coder

Summary:  The Rural Health Clinic coder plays a critical role in ensuring accurate and compliant medical coding for all patient encounters.

Essential Duties and Responsibilities include the following; other duties may be assigned.

• Reviews medical records and other relevant documentation to accurately assign diagnostic and procedural codes. 
• Assigns appropriate ICD-10-CM, CPT, and HCPCS Level II codes based on documented diagnoses and procedures. 
• Ensures compliance with all relevant coding guidelines, including but not limited to National Correct Coding Initiative (NCCI) edits and payer-specific coding requirements. 
• Evaluates clinical documentation to ensure completeness, accuracy, and specificity for coding purposes. 
• Collaborates with healthcare providers and other staff to clarify documentation as needed to support accurate coding. 
• Communicates effectively with healthcare providers, clinical staff, and administrative personnel to obtain necessary documentation and resolve coding-related issues. 
• Collaborates with other members of the healthcare team to improve documentation practices and coding accuracy. 
• Adheres to all applicable laws, regulations, and industry standards related to medical coding and healthcare operations, including but not limited to HIPAA, Stark Law, and Anti-Kickback Statute. 
• Maintains strict confidentiality and security of patient health information in accordance with HIPAA regulations. 
• Participates in ongoing training and education to stay current with coding guidelines, regulations, and best practices. 
• Maintains accurate records of coding assignments and audit findings. 
• Prepares reports summarizing coding accuracy, trends, and areas for improvement. 

Education and/or Experience                                                  

High school diploma or general education degree (GED).  At least one (1) year experience and a certification in Coding preferred.