Outpatient Medical Coder

HealthCare Resolution Services
North Carolina

Job Description

Job Description

Summary:
Responsible for assignment of accurate Evaluation and Management (E&M) codes, ICD diagnoses, current procedural terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS), modifiers, and quantities derived from medical record documentation (paper or electronic) for outpatient encounters. Trains and educates MTF staff on coding issues and plays a significant role in coding compliance activities.

Duties & Responsibilities:

  • Responsible for the assignment of accurate E&M, ICD, CPT, and HCPCS codes and modifiers from medical record documentation.
  • Identifies and abstracts information from medical records (paper or electronic) for special studies and audits, internal and external.
  • Interacts with MTF staff to ensure documentation is clear and supports coding assignments.
  • Educates MTF staff through individual or group in-services and training sessions.
  • Maintains a delinquency report of missing records in order to facilitate the completion of work within the required thresholds.
  • Position requires excellent computer/communication skills for provider and staff interactions.
  • Knowledge of anatomy/physiology and disease process, medical terminology, coding guidelines (outpatient), documentation requirements, familiarity with medications and reimbursement guidelines; and encoder experience.
  • Candidate must have the ability to handle multiple projects and appropriately prioritize tasks to meet deadlines.

Requirements:

  • Registered Health Information Technologist (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder (CPC) CCS-P (Certified Coder Specialist - Physician (CCS-P) with the appropriate level of experience.
  • An accrediting institution recognized by the American Health Information Management Association (AHIMA) and/or the American Academy of Professional Coders (AAPC) must accredit education.
  • CONTINUED EDUCATION REQUIREMENTS: Contract medical coders will obtain the required continued education hours at no expense to the government in order to maintain the current and proper national certification(s) required for the position.
  • Experience. A minimum of three years of experience in the outpatient setting (physician's office or ambulatory surgery centers) within the last five years, including assignment of E&M, CPT, and HCPCS codes.
Posted 2025-07-27

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