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Position Summary
The Certified Medical Coder reviews clinical documentation and assigns medical codes in accordance with established guidelines, documentation standards, and organizational procedures. This individual contributor role supports compliant billing, accurate revenue cycle outcomes, and timely resolution of documentation issues through appropriate escalation.
Qualifications
Required
- Active professional coding certification (e.g., CPC, CCS, equivalent)
- Working knowledge of medical coding guidelines and documentation standards
Preferred
- Prior experience in medical coding or revenue cycle operations
- Familiarity with EHR and coding systems
Key Responsibilities and Expected Performance Outcomes
Key Responsibilities
- Review assigned encounters and clinical documentation each day to support complete, accurate coding.
- Assign medical codes in accordance with current coding guidelines, documentation standards, and organizational procedures.
- Validate documentation before coding to identify missing, unclear, or conflicting information.
- Apply coding standards consistently and avoid unsupported assumptions, informal interpretations, or workarounds.
- Escalate documentation gaps, guideline conflicts, compliance concerns, or scenarios outside defined authority to Team Leads or Supervisors with relevant facts and documentation references.
- Maintain accurate coding records and supporting documentation for assigned work.
- Use assigned EHR, coding, and workflow systems to complete coding tasks and document work activity.
- Communicate workload status, risks, and questions clearly to Team Leads or Supervisors.
- Participate in coding updates, training, and feedback to stay aligned with current standards and process expectations.
Expected Performance Outcomes
- Support clean, compliant claims by producing accurate coding with minimal rework.
- Improve revenue cycle reliability by applying coding standards consistently across assigned encounters.
- Reduce operational risk by identifying documentation gaps, ambiguities, conflicts, or compliance concerns before they create downstream rework.
- Protect coding quality and workflow stability by prioritizing accuracy, documented guidance, and timely escalation over unsupported shortcuts.
Core Competencies (Required for All Employees)
- Critical Thinking: Applies judgment to routine coding scenarios using established guidance and recognizes when escalation is required
- Dependability: Consistently meets accuracy and timeliness expectations while working within defined authority
- Interpersonal Skills: Communicates clearly, professionally, and with appropriate context when surfacing risks or questions
- Organizing & Planning: Manages assigned workload effectively and prioritizes accuracy over unsupported speed tradeoffs
- Production: Produces accurate, compliant coding without reliance on rework, informal fixes, or heroics
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