*Certification and experience is required*


  • Provides in an atmosphere of healthcare service that contributes to the physical, psychological, emotional, and spiritual well being of each person served.
  • Under the general directions of the Team Leader, Medical Record Department, this specialist is responsible for accurate coding of all inpatient, outpatient, and emergency service diagnosis and conditions, working from the appropriate documentation in the Medical Record of the patient.
  • Reviews medical records and abstracts key data elements to facilitate the billing process and to maintain a clinical and financial database. Performs duties in support of the medical center mission to ensure the highest quality of patient care in economically sound and efficient manner.


  • High school degree or equivalent required.
  • Education required for Certified Coding Specialist (CCS) or related coding certification, Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA).
  • Advanced knowledge in medical and anatomical terminology, clinical medicine theory, and reimbursement principles.
  • In-depth knowledge of medical record content and sequence.
  • Knowledgeable of use of Coding Software
  • In-depth knowledge of coding/classification systems appropriate for inpatient, outpatient, and emergency care, specifically ICD-10-CM/PCS, and CPT-4.


  • CCS, CCA, CPC, RHIT, or RHIA required.


A. Assigns ICD-10-CM/PCS diagnostic and procedure codes and CPT procedure codes following approved guidelines for coding on all cases within 24 hours after discharge unless waiting for further documentation.

B. Assigns DRG codes for inpatient charts.

C. Accurately codes all procedures provided by ancillary departments such as laboratory and radiology.

D. Contacts providers to obtain missing documentation or dictation needed to facilitate coding.

E. Performs routine audits to ensure that all accounts with activity have been billed.


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