Primary Care Coder

About the role

United Health Services (UHS) is seeking a Primary Care Coder to accurately assign ICD-10, CPT, and applicable modifier codes to patient health information across a variety of outpatient and clinical practice settings. This role supports coding activities for internal medicine, family practice, pediatrics, hospitalist services, walk-in clinics, specialty practice evaluation and management services, and emergency department encounters. The Coding Specialist plays a critical role in ensuring accurate documentation, data retrieval, claim processing, and reimbursement.

Responsibilities

• Assign accurate ICD-10 diagnosis, CPT procedure, and HCPCS codes, including appropriate modifiers, in accordance with payer requirements, regulatory standards, and organizational policies.
• Review clinical documentation to ensure coding accuracy, completeness, and compliance with reimbursement guidelines.
• Enter and validate professional and technical charges based on medical record documentation and established departmental procedures.
• Monitor and resolve coding-related work queues, claim edits, and billing exceptions in a timely manner to support clean claim submission.
• Query physicians and other healthcare providers to clarify incomplete, ambiguous, or conflicting documentation necessary for accurate code assignment.
• Abstract and document pertinent patient and encounter information from medical records using designated coding and billing software applications.
• Maintain established productivity, quality, and accuracy standards while identifying and escalating coding concerns to leadership as appropriate.
• Stay current with ICD-10, CPT, HCPCS, Medicare, Medicaid, commercial payer, and regulatory coding requirements to ensure ongoing compliance.
• Adhere to patient confidentiality, release of information, medical record amendment, and other medico-legal policies in accordance with organizational and regulatory standards.
• Uphold the AHIMA and AAPC Standards of Ethical Coding while completing required continuing education activities and maintaining applicable coding certifications.

Requirements

• High School Diploma
• 1 year relative medical billing or coding experience

Preferred Qualifications

• Associates Degree in HIT with RHIT or CPC, CCA, CCS-P or CCS certification.
• 3 years of medical coding/billing experience
• CPT and ICD-10 coding knowledge.
• Ability to read and understand explanation of benefits and ANSI/remark codes.