Professional Medical Coder

Job Summary

The Medical Coder (Inpatient & Outpatient) is responsible for accurately translating clinical documentation into standardized medical codes to ensure compliant billing, appropriate reimbursement, and reliable clinical data reporting. This role reviews medical records, assigns ICD-10-CM/PCS, CPT, and HCPCS Level II codes as applicable, and ensures adherence to coding guidelines, payer requirements, and regulatory standards for both inpatient and outpatient encounters.

Key Responsibilities

• Review and analyze inpatient and outpatient medical records, including histories and physicals, progress notes, operative reports, discharge summaries, and diagnostic results.
• Assign accurate and complete diagnosis and procedure codes using ICD-10-CM, ICD-10-PCS (inpatient), CPT, and HCPCS Level II (outpatient).
• Ensure coding accuracy, completeness, and compliance with official coding guidelines, CMS regulations, and payer-specific policies.