A medical coder, also known as a certified coding specialist, reviews, analyzes, and assigns accurate medical codes for diagnoses, procedures, and services provided to patients. This role ensures compliance with regulatory guidelines, optimizes reimbursement, and supports data quality for healthcare organizations.

Key Responsibilities:

1. Review medical records and documentation to assign accurate ICD-10-CM, CPT, and HCPCS codes.

2. Ensure coding accuracy, consistency, and adherence to regulatory guidelines (e.g., CMS, OIG, HIPAA).

3. Conduct coding audits and quality checks to identify areas for improvement.

4. Stay updated on coding guidelines, updates, and industry developments.

5. Collaborate with healthcare providers to clarify documentation and coding discrepancies.

6. Perform data entry and maintain electronic health records (EHRs).

7. Participate in coding education and training programs.

8. Analyze and report coding data for quality improvement initiatives.

9. Ensure confidentiality and security of patient information.

10. Maintain certification and continuing education requirements.