Assistant Clinical Coder

About the role

The Assistant Clinical Coder supports the coding team by abstracting and analyzing clinical information from medical records and translating it into accurate diagnostic and procedural codes. This position ensures compliance with coding standards and contributes to the timely processing of patient records.

Key responsibilities

• Assign codes for diagnoses, treatments, and procedures using the appropriate classification system for outpatient, emergency, and observation stays.
• Review provider documentation to determine principal diagnosis, comorbidities, complications, secondary conditions, and surgical procedures.
• Adhere to official coding guidelines to maintain accuracy and completeness.
• Clarify diagnosis and procedural information through a query process with physicians.
• Assign Present on Admission (POA) values for inpatient diagnoses.
• Verify physician names, service dates, and times for each coded encounter.
• Interact with physicians and other departments to obtain additional coding information and prevent medical necessity denials.
• Maintain production targets and coding accuracy while meeting regulatory timeframes.
• Participate in coding query training and uphold ethical coding standards set by AHIMA.

Required profile

• Minimum 3 years of progressive experience in clinical coding or a similar role.
• Bachelor’s degree in Health Information Management or a related field, or a diploma with at least 3 years of relevant experience.
• Experience in a large healthcare facility is desirable.

Required skills

• Clinical coding and medical record abstraction.
• Knowledge of coding classification systems and AHIMA coding guidelines.
• Ability to conduct coding queries and communicate effectively with physicians.
• Understanding of POA assignment and regulatory coding requirements.

What we offer

• Opportunity to work within a reputable healthcare organization.
• Professional development in clinical coding standards.