Medical Records Coder-Senior

About the role

Under direct supervision, responsible for conducting review of inpatient and outpatient coding, assuring coding compliance with federal regulations, and maintaining up-to-date coding guidelines and coding policy changes.

Responsibilities

• Reviews, interprets, and assigns diagnostic and procedural codes based upon medical record documentation according to correct coding principles.
• Provides technical work in documentation and coding for medical billing, abstracts patient-related data from medical records and coding of diagnoses and procedures using ICD-10 and CPT codes.
• Works coding related charge review and claim edits daily to ensure timely and accurate billing.
• Obtains medical records and charge fee information from patient care area.
• Contacts other facilities to obtain medical records and information needed to bill for services rendered.
• Verifies charge capture and physician notes for completeness to include abstracting and entering relevant medical information from the medical records; checks for required signatures; ensures proper documentation guidelines are followed.
• Codes diagnosis and procedures using classification coding systems.
• Reviews charge documents for completeness.
• Performs all other duties as assigned.

Qualifications

• Proficiency in ICD-10 and CPT coding.
• In-depth understanding of medical terminology, anatomy and physiology.
• Meticulous attention to detail and accuracy.
• A solid customer service acumen and interpersonal skills to effectively work with both internal and external customers and respond to requests in a timely and respectful manner.
• Strong verbal, written and interpersonal communication skills.
• Accreditation from a professional coding organization, such as American Health Information Management Association (AHIMA), American Academy of Professional Coders (AAPC), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Specialist (CCS) certification is required.

About Us

UT Health San Antonio offers an excellent benefits package for its employees. Employees who work at least 20 hours a week, with an appointment of at least 4.5 months, are eligible for benefits. Benefits include medical, dental, vision, disability, FSA, retirement, time off, and discounts.