Medical Billing Coder

Job Summary

Reviews billing data from medical office or hospital records to ensure accuracy, responsible for account posting, collections, and verifying patient benefits. Assigns precise CPT, ICD-10, HCPCS (and when applicable, APC/DRG) codes to all services performed, including radiology imaging, neuro procedures, office consultations, and lab tests.

Essential Functions

• Review and analyze patient records and physician documentation for completeness and accuracy, focusing on areas such as radiology reports, neurological procedures, office visit notes, and laboratory results.
• Assign precise CPT, ICD-10, HCPCS (and when applicable, APC/DRG) codes to all services performed, including radiology imaging, neuro procedures, office consultations, and lab tests.
• Maintain updated knowledge of new coding guidelines, compliance standards, and payer policy changes, especially regarding specialized coding for neuro and radiology services.
• Liaise with physicians and clinical staff to clarify ambiguous documentation and provide feedback for improved coding compliance.
• Conduct chart audits and support internal or external coding reviews, contributing to quality assurance and compliance efforts within the organization.
• Communicate any identified coding issues or discrepancies to the supervisor or compliance officer to safeguard billing integrity.
• Train new staff and educate providers on documentation and coding improvements, following industry best practices for all clinical areas.
• Ensure patient confidentiality and follow HIPAA guidelines.
• Promote a professional image by adhering to the established dress code as listed in Employee Handbook.
• Check and resolve assigned tasks in EMR program.
• Afford assistance to co-workers as needed.
• Recognize when others are in need of assistance, information or directions and offer to help when able, or find someone who can.
• Maintain emotional control and diplomacy at all times.
• Maintain open and positive lines of communication.
• Consistently report to work on time, begins work promptly and perform duties for entire scheduled shift.
• Notify Administration of absences and tardiness in a timely manner.
• Read new policies and documents as instructed.
• Adhere to company policies and procedures.
• Demonstrate sensible and efficient use of equipment and supplies by limiting waste, spoilage or damage.

Knowledge Performance Requirements

• Knowledge of medical billing and collection practices.
• Knowledge of basic medical coding.
• Knowledge of third-party payer operating procedures and practices.
• Knowledge of Medicare requirements.
• Comprehensive knowledge of medical terminology, anatomy, and clinical procedures for office visits, radiology, neuro, and lab services.

Skills

• Proficient skills in computer programs.
• Skill in trouble-shooting insurance claims and problems.
• Skill in establishing and maintaining effective internal and external working relationships.
• Proficiency in using medical coding software and electronic health records systems.

Abilities

• Ability to accurately enter data and examine insurance documents.
• Ability to deal courteously with patients, staff and others.
• Attention to detail.
• Strong organizational skills.
• Effective written and verbal communication skills.

Qualifications

• A High School Diploma or GED required.
• Certified Professional Coder (CPC) required.
• Minimum two years’ experience preferred.

Physical Requirements

• Ability to work effectively in a fast-paced environment.
• Physical ability to sit, perform data entry and view computer screen for long periods at a time.
• Occasional exposure to communicable diseases and biohazards.
• Daily standing, walking, bending, and maneuvering.
• May require lifting up to 50 pounds or more to transfer and/or turn patient with and without assistive devices.