1. Codes and abstracts an average of 40-50 inpatient and/or outpatient records daily.

2. Responsible for maintaining the AR days under 4 days.

3. Reviews the Bill Hold report daily to assure that bills are dropped in a timely manner.

4. Reviews the Coding Clinic, Coding Compendium and other publication to assure coding accuracy.

5. Interact with physicians on a daily basis for clarification of diagnosis and optimization of the DRG.

6. Interacts with Case Management on a daily basis for assistance with utilization review, length of stay and DRG.

7. Responsible to maintain 95% accuracy.

8. Assist with clinical pertinence collection of data as needed.

9. Refers to the Health Information Management Director any issues of quality that may arise in the medical record.

10. Keeps informed of changes of guidelines by reviewing coding newsletters and attending seminars.

11. Interacts with Admitting Department for clarification of certain diagnosis.

12. Interacts with Business Office for coding and physician’s issues and other matters that will prevent a bill to drop.

13. Assist Case Management in the PEPP Project and other reports.

14. Participate in QI process.

15. May be cross trained in other areas where applicable.

16. May be required to vary shifts and work weekends as the needs of the department dictate.

17. May include overtime.

18. Performs other related duties as requested.


  • · Use language and mathematical skills to analyze and interpret reports and related material.
  • · Use special record keeping procedures.
  • · Recognize errors in recorded information.
  • · Perform routine and repetitive work.
  • · Excellent computer skills.
  • · Knowledge of 3M Encoder.
  • · Medical Terminology.
  • · Principles of disease.
  • · Use of appropriate ICD-10 codes and CPT (Current Procedure Terminology) for diagnosis and procedures.
  • · Anatomy and Physiology.
  • · Medical Terminology.


Education and/or experience:

  • An occupationally significant combination of formal and/or on-the-job training in Coding. Prior experience within Health Information Management field.
  • Associate Degree in Health Information Management and credentialed as a Registered Health Information Technician and/or Certified Coding Specialist.
  • Minimum of 3 years’ experience.

Job Type: Full-time


  • 401(k)
  • 401(k) matching
  • Dental insurance
  • Disability insurance
  • Employee assistance program
  • Health insurance
  • Life insurance
  • Tuition reimbursement
  • Vision insurance