Coder Job Description

Healthcare payers and provider groups operate under CMS Risk Adjustment and ICD-10-CM guidelines that determine whether diagnosis coding withstands HHS-RADV audit scrutiny. Coding errors carry real compliance risk. The Coder exists to keep documentation defensible, translating physician records into validated ICD-10-CM, CPT, and HCPCS codes across inpatient, outpatient, and risk adjustment settings. Sitting within the health information or coding department, the Coder owns accuracy at the individual chart level, distinct from auditors who evaluate coding programs rather than single records.

You will own the accuracy of diagnosis and procedure coding across patient encounters, serving as the Coder who assigns ICD-10-CM, CPT, and HCPCS codes from provider documentation. Working alongside coding auditors and health information leadership, the role turns clinical documentation into compliant, reimbursable code sets that support payer audits and revenue integrity.

Career Impact: Building expertise in CMS HCC risk adjustment and multi-specialty ICD-10-CM coding strengthens a path toward coding auditor and documentation specialist roles.

Business Impact: Accurate charge and diagnosis coding protects reimbursement integrity and keeps organizations audit-ready under HHS-RADV and payer review.

Growth Opportunity: Coders who master CPT, HCPCS, and risk adjustment coding can advance toward senior auditing, HCC specialist, or documentation improvement positions.

• Assign ICD-10-CM, CPT, and HCPCS codes to diagnoses and procedures based on provider documentation.
• Review medical record documentation to verify that coding matches the patient encounter and payer guidelines.
• Query physicians to resolve documentation gaps or clarify diagnosis and procedure details.
• Audit chart-level coding accuracy against CMS Risk Adjustment and payer-specific guidelines.
• Reconcile coded charges against posted charges to identify and resolve discrepancies.
• Report coding trends, discrepancies, and risk factors to coding leadership.
• Support quality and compliance initiatives, including RAF and RADV audit preparation.

• High school diploma or equivalent, or work experience.
• 2 or more years of medical coding experience, with exposure to ICD-10-CM and CPT coding.
• Active coding certification such as CPC, CCS, or CCS-P.
• Strong knowledge of ICD-10-CM, CPT, and HCPCS coding guidelines and conventions.
• Working knowledge of medical terminology, anatomy, and physiology.
• Ability to review clinical documentation and identify coding discrepancies.
• Strong written and verbal communication skills for provider queries and audit reporting.

• Experience with CMS HCC risk adjustment coding and RADV audit processes.
• Familiarity with electronic medical record and encoder software systems.
• Prior experience training or mentoring junior coders or providers on documentation standards.

• Coding accuracy rate, measuring the percentage of charts coded correctly against audit review.
• Query turnaround time, tracking how quickly documentation clarifications are resolved with providers.
• Charge discrepancy rate, reflecting how often posted charges differ from coded procedures.
• Coding productivity, measured in charts or encounters coded per day against departmental targets.
• RADV or internal audit pass rate, showing how well coded charts withstand compliance review.

• Base Salary Range: $40,000 to $52,000 per year
• Bonus: Up to 3 percent annual performance bonus
• Equity: Not typically offered for this role
• Health Benefits: Medical, dental, and vision insurance
• PTO: 10 to 15 days annually, plus paid holidays
• Common Perks: Remote or hybrid options, certification reimbursement

Figures are estimates based on general US market benchmarks and may be outdated. Adjust based on location, company size, and seniority level.

All qualified applicants will be considered for employment without regard to race, color, religion, sex, national origin, age, disability, or any other status protected by applicable federal, state, and local law. Employment is contingent upon successful completion of a background check, consistent with healthcare industry requirements. Candidates who need reasonable accommodation under the ADA to complete the application or interview process may request one. All applicants must be authorized to work in the United States.

The Coder owns diagnosis code validation for outpatient risk adjustment reviews, verifying that ICD-10-CM coding reflects provider documentation and eliminating unsubstantiated codes to protect coding accuracy and compliance. Reporting to Quality Leadership, the Coder partners with provider offices to resolve documentation gaps and supports RAF compliance audits across the risk adjustment program.

Key Responsibilities

• Verify diagnosis codes are supported by provider documentation according to ICD-10-CM guidelines, supplemental internal guidelines, and project and client guidelines.
• Verify documentation for current management or monitoring of conditions.
• Eliminate diagnosis codes unsubstantiated by the record.
• Capture the severity of illness of patients through clinical indicators and provider queries.
• Abstract and add new diagnosis codes when opportunities arise.
• Meet and exceed productivity and coding accuracy standards set by Quality Leadership.
• Conduct research utilizing approved resources when needed to complete record reviews.
• Deliver direct feedback to provider offices per internal policy.
• Conduct practice documentation and coding audits for RAF compliance when assigned.
• Ensure compliance with established protocols, procedures, and applicable federal, state, and county laws and regulations related to coding and documentation guidelines for risk adjustment.
• Stay current with risk adjustment rules and regulations through regulatory agencies, including CMS, HHS, and OIG work plans.
• Stay current with coding, compliance, and documentation guidelines.
• Handle highly sensitive and confidential information in compliance with HIPAA and internal confidentiality policies.
• Support and participate in quality improvement initiatives, and report provider documentation and submittal trends to Quality Leadership.

Required Qualifications

• Active coding certification such as CPC, CPC-H, CCS-P, CCS, or CRC.
• 3 or more years of Risk Adjustment coding experience.
• Experience with CDPS and National RAD-V processes.
• Proven knowledge and understanding of CMS HCC Risk Adjustment coding and data validation requirements.
• Strong knowledge of medical terminology, pharmacology, body systems, anatomy, physiology, disease processes, and clinical practice.
• Proven knowledge and understanding of ICD-10-CM coding and documentation guidelines.
• Proficiency in HHS-HCC Risk Adjustment coding and data validation requirements.
• Proficiency in Microsoft Office applications and web-based technologies.
• Demonstrated ability to use a variety of electronic medical records systems.
• High degree of accuracy, efficiency, flexibility, and dependability.
• Excellent verbal, written, and interpersonal communication skills, with a highly collaborative team approach.
• Strong problem-solving skills, including the ability to systematically analyze problems, draw relevant conclusions, and devise appropriate courses of action.
• Ability to convey complex or technical information in a manner that others can understand, and to interpret complex information from others.

Embedded within a physician practice's coding and compliance function, the Coder delivers chart audits and coding compliance training that keep provider documentation aligned with official coding guidelines and payer regulations. Working closely with the Manager of Coding and Auditing, the Coder builds practitioner education programs and reports audit findings that support compliant, defensible coding across the practice.

Core Functions

• Maintain current knowledge of coding guidelines and relevant federal regulations through the use of current CPT-4, HCPCS II, and ICD-10 materials, the Federal Register, and other pertinent materials.
• Abide by all ethical standards and adhere to official coding guidelines.
• Conduct physician chart audits, including research and presentation.
• Assist with implementation of billing policies and procedures across all centers.
• Assist with formal training programs for physicians and clinical staff by determining training needs.
• Assist the Manager with researching, analyzing, and responding to inquiries regarding compliance, coding, and inappropriate coding.
• Train, instruct, and provide technical support to physicians and staff on coding compliance provisions and third-party payer requirements.
• Provide oversight of other coder and auditor team members as delegated by the Manager of Coding and Auditing.
• Develop practitioner and staff education opportunities and provide coding and audit result reporting.
• Conduct training sessions for physicians and staff on documentation guidelines, Medicare and Medicaid regulations, and the Correct Coding Initiative.
• Assist and direct other coders and staff on coding opportunities and reimbursement issues.

Qualifications & Experience

• High school diploma, GED, or equivalent.
• Coding certification through AAPC or AHIMA.
• 3 or more years of coding experience.
• Prior supervisory experience, such as oversight of coder or auditor team members.
• Excellent understanding of ICD-10-CM coding classification and guidelines.
• Solid grasp of CPT, HCPCS, and modifier coding and guidelines.
• Excellent understanding of medical terminology, disease process, anatomy, and physiology.
• Good organizational and communication skills.
• Ability to stay task-oriented and meet designated deadlines and productivity standards.
• Solid interpersonal skills and excellent customer service skills.
• Ability to present a professional image when interacting with all levels of staff.
• Fluency in reading, writing, and speaking the English language.

Reporting to Coding department leadership, the Coder leads accurate ICD, CPT, and HCPCS code assignment across provider documentation, resolving inaccuracies and safeguarding reimbursement integrity. Partnering with coding peers, the Coder recommends policy updates and processes payer appeals that keep coding practices aligned with current government regulations.

Primary Duties

• Assign codes using ICD, CPT, and HCPCS.
• Sequence diagnoses and procedure codes per ICD, CPT, and HCPCS coding guidelines while adhering to local and national payer guidelines.
• Adhere to organizational and departmental guidelines, policies, and protocols.
• Maintain the confidentiality of patient records and report any perceived non-compliant practices to the coding leader or compliance officer.
• Review all provider documentation to support assigned codes so that significant diagnoses and procedures are captured for reimbursement and data purposes.
• Follow up and obtain clarification of inaccurate documentation as appropriate.
• Abide by the Standards of Ethical Coding set by AHIMA and AAPC.
• Practice ethical judgment in assigning and sequencing codes.
• Meet and exceed departmental quality and production standards.
• Serve as a subject matter expert to coding department leaders and peers, recommending modifications to current policies and procedures to align with government regulations.
• Participate in payer audits as a resource for coding-related audits, as requested.
• Process coding claim appeals and coding claim rejections when applicable.

Skills & Qualifications

• 2 or more years of experience in professional coding.
• Advanced knowledge of ICD, CPT, and HCPCS coding guidelines.
• Advanced knowledge of medical terminology, anatomy, and physiology.
• Intermediate computer skills, including Microsoft Office and email, with exposure to electronic coding systems or applications.
• Excellent oral and written communication and interpersonal skills.
• Excellent organization, prioritization, and reading comprehension skills.
• Excellent analytical skills, with close attention to detail.
• Capacity to function as a mentor, role model, and teacher.
• Ability to work independently and exercise independent judgment and decision-making.
• Comfort working under deadlines in a demanding, high-volume environment.
• Ability to take initiative and work collaboratively with others.

Sitting at the intersection of MS-DRG assignment and APC classification, the Coder shapes accurate diagnosis and procedure coding for hospital reimbursement using ICD-9-CM and CPT-4 guidelines. Operating across practice staff and the Coding Manager, the Coder reconciles charge discrepancies and keeps billing submissions compliant with organizational coding standards.

Duties

• Abstract information from the medical record into the appropriate coding systems, ensuring compliance with established guidelines.
• Determine the most appropriate diagnosis after a thorough review of the medical record.
• Work closely with practice staff on coding and assignment of MS-DRGs and APCs.
• Code medical records using ICD-9-CM and CPT-4 coding rules and guidelines.
• Ensure thorough and compliant coding to support patient records and submission of billing for payment.
• Sequence diagnostic and procedural codes according to organization-specified procedures and assign MS-DRG or APC as appropriate.
• Provide codes to various departments upon request.
• Enter and validate charges using appropriate tools and validate diagnoses against the medical documentation provided.
• Compare charges on accounts with the procedures coded and identify any discrepancies.
• Notify the Coding Manager of discrepancies and collaborate to rectify the account.

Requirements

• High school diploma or equivalent, required.
• Associate degree in a related field, preferred.
• Completion of a college-level course in medical terminology, anatomy and physiology, disease processes, and pharmacology, preferred.
• Certification through AHIMA as one of the following, preferred: RHIT, RHIA, CCS, or CCS-P.
• Certification through AAPC as one of the following, preferred: CPC-H or CPC.

A key member of the hospital coding team, the Coder builds accurate CPT, HCPCS, and ICD-10-CM code assignments for high-volume Trauma Level 1 and academic teaching facility encounters. Collaborating across ancillary, emergency, and outpatient service lines, the Coder resolves documentation deficiencies through physician queries and safeguards reimbursement and quality standards.

Functions

• Assign codes for reimbursement, research, and regulatory compliance, utilizing guidelines and coding conventions.
• Account for coding and abstracting of patient encounters, including diagnostic and procedural information, significant reportable elements, and complications.
• Analyze medical records and identify documentation deficiencies.
• Review and verify that documentation supports existing diagnoses, procedures, and other charges.
• Identify reportable elements, complications, and other quality measures.
• Communicate with physicians to clarify information through the physician query process.
• Assign CPT, HCPCS, and ICD-10-CM codes.
• Maintain required productivity and quality standards.
• Adhere to organizational competencies and standards of behavior.

Experience & Qualifications

• High school diploma or higher.
• 4 or more years of coding experience in a Trauma Level 1 and academic teaching facility.
• Knowledge of and ability to address National Correct Coding Initiative and National Coverage Determination or Local Coverage Determination edits.
• Strong understanding of physiology, medical terminology, and anatomy.
• Proficient in coding ancillary accounts such as diagnostic radiology and cardiology.
• Skilled in coding emergency department and infusion-based services such as oncology.
• Proficient in coding observation and procedure room services such as endoscopies and cardiac catheterization.
• Experienced in coding all outpatient services, especially operating room procedures.
• Proficient in computer skills, including typing speed and accuracy.
• Proficient in computer skills, including Microsoft Office and Google Suite platforms.
• Excellent written and verbal communication skills.

Accurate, audit-ready patient records depend on the Coder, who verifies patient information, assigns and sequences diagnostic and procedural codes, and flags documentation trends that could affect compliance. Based within the health information team, the Coder safeguards record integrity by reporting discrepancies and risk factors to management.

Accountabilities

• Verify patient information and work with caregivers to obtain clarification of patient diagnoses.
• Identify misplaced or potentially litigious documentation and report findings to management.
• Review records for accuracy of scanned documents and report poorly scanned documents to management.
• Collaborate with other departments to ensure records accurately reflect services provided and to identify documentation trends.
• Assign and sequence diagnostic and procedural codes to encounters.
• Report unusual circumstances, possible risk factors, problems, errors, and discrepancies to management.
• Survey caregivers on documentation issues and coding idiosyncrasies.
• Maintain current knowledge of coding rules and regulations.
• Adhere to institutional policies and procedures and safeguard institutional assets.

Technical Qualifications

• High school diploma or equivalent.
• Certified Coding Specialist, RHIT, or RHIA certification.
• 1 or more years of relevant experience.
• General knowledge of office procedures and operations.
• Ability to accurately prepare and maintain records, files, reports, and correspondence.
• Ability to communicate effectively in both oral and written form.
• Skill in completing assignments accurately and with attention to detail.

As the Coder, this role owns HCC coding accuracy across Medicare Advantage, Commercial, and Medicaid records, auditing provider documentation against CMS Risk Adjustment guidelines and resolving discrepancies through the physician query process. The coding and compliance team relies on this work to pass HHS-RADV audits and strengthen provider documentation practices.

Activities

• Audit medical records from coding vendors and network providers to ensure diagnosis coding accuracy.
• Audit medical records to determine coding accuracy against coding standards and CMS regulations.
• Evaluate medical records for appropriate written and electronic signatures and other technical requirements.
• Collaborate with the QA team and vendors to identify and submit coding adjustments as needed.
• Perform HHS-RADV audits, including preparing charts for Initial Validation Auditor review.
• Evaluate Initial Validation Auditor results and provide ICD-10-CM guidelines, AHA Coding Clinic guidance, or CMS guidelines to support code assignment validity.
• Maintain a current and strong understanding of coding rules and CMS guidelines in inpatient and outpatient settings.
• Interpret and summarize coding guidelines and CMS regulations for leadership.
• Incorporate changes to guidelines and regulations into audit practice.
• Research and resolve coding and risk adjustment regulatory issues.
• Evaluate internal and vendor coding program opportunities and summarize recommendations for key internal staff.
• Review reports from coding vendors, identify and evaluate coding issues, and summarize findings and recommendations for leadership.

Position Requirements

• Business degree or relevant experience, preferred.
• Completion of a formal coding certification program, required.
• Certified Professional Coder (CPC, CPC-H, COC, CIC) or Certified Coding Specialist (CCS-P or CCS), required.
• Certified Risk Adjustment Coder certification, strongly preferred; required by the end of the first year of employment.
• 5 or more years of coding experience in a health plan, hospital, or physician practice billing or hospital care management environment, preferred.
• Prior experience with risk adjustment coding and auditing, preferred.
• Thorough knowledge of ICD-9-CM and the documentation needed to support it.
• Clear and succinct writing skills across a variety of communication settings and styles.
• Ability to interact with providers and other office staff through presentations and face-to-face meetings.
• Capacity to train providers on documentation required to support ICD-9 and HCC codes, a plus.
• Excellent problem-solving ability and strong interpersonal skills.
• Effective communication with multi-level personnel, medical professionals, clients, and the public.
• Self-starter with the ability to learn quickly.
• Ability to work on multiple projects or accounts simultaneously with frequent interruptions.

Coder builds accurate inpatient, observation, ambulatory surgery, and emergency department code assignments using ICD-10-CM, ICD-10-PCS, and CPT within a hospital health information team. Success in the position means keeping the final bill pending report within target while advising medical staff and quality management on coding issues.

Operational Focus

• Review patients' entire current medical records and use encoder software or code books to assign appropriate diagnosis codes using ICD-10-CM, following coding guidelines and department standards.
• Determine the sequence of diagnoses according to uniform hospital discharge data.
• Review surgical and designated diagnostic procedure documentation to assign appropriate procedure codes using ICD-10-PCS or CPT, using encoder software or code books.
• Determine and record other required data items, including attending physician, discharge disposition, number of consultations, and referral source.
• Query physicians or other providers to obtain documentation clarification or other information required for accurate code assignment.
• Assist in the care and maintenance of department equipment and supplies, and maintain department records, reports, and files as required.
• Participate in educational programs and in-service meetings, and attend other meetings as required.
• Advise medical staff, the business office, and quality and risk management staff on coding issues.
• Ensure the final bill pending report is within target and that charts are coded within specified timeframes.
• Retrieve records for month-end closing and make corrections to coded and abstracted information as required.

Knowledge, Skills & Abilities

• Bachelor's degree.
• Vocational certificate.
• Registered Health Information Administrator, Registered Health Information Technician, or Certified Coding Specialist certification upon hire, required.
• 5 or more years of prior coding experience, required.
• Knowledge of how related teams affect achievement of objectives, and regularly interacts with other teams.
• Has developed breadth or specialized skills across a range of processes, procedures, and systems, or acts as technical expert within the discipline.
• Clearly and accurately conveys complex, potentially sensitive, or controversial information.

The Coder produces accurate primary diagnoses and procedural coding for designated specialty and surgical areas, auditing physician charts and abstracting codes directly from source documentation for CPT and ICD-10. Reporting to the Billing Manager, the Coder enters coded patient services into the electronic medical record system and serves as a liaison for physician documentation improvement.

Key Deliverables

• Audit, code, and enter patient services into the electronic medical record system.
• Sort and file paperwork and handle insurance claims.
• Code primary diagnoses and procedures for designated specialty areas and other major procedural areas.
• Perform detailed physician chart abstraction and serve as liaison for documentation improvement and optimization of physician coding practices.
• Identify codes for surgical abstraction coding based solely on source documentation for CPT and ICD-10.

Professional Experience

• High school diploma or equivalent, required.
• Graduation from an accredited medical coding program, preferred.
• Certified Professional Medical Auditor, Certified Coding Specialist, or Certified Coding Specialist Professional from AHIMA, or Certified Professional Coder from AAPC, required within 9 months of hire.
• 2 or more years of certified coding experience in a physician or medical group, multi-specialty, or surgical practice.
• Extensive knowledge of coding surgical procedures and applicable modifiers in a multi-specialty setting, code auditing for compliance and revenue maximization, and applicable Centers for Medicare and Medicaid Services guidelines.
• Advanced knowledge of ICD-10-CM and CPT-4 coding conventions, anatomy and physiology, and medical terminology.
• Excellent written and verbal communication skills.

Embedded within a hospital's professional billing and compliance function, the Coder develops accurate ICD, CPT, and HCPCS Level II code assignments for professional charges while tracking coding variance across departments. Working closely with billing leadership, the Coder reconciles charges against coded procedures and resolves discrepancies to protect third-party payer compliance.

Areas of Ownership

• Abstract information from the medical record and assign ICD-9-CM, ICD-10-CM, CPT-4, and HCPCS level II codes in compliance with established guidelines.
• Provide codes to various departments upon request.
• Review supporting medical record documentation to ensure accurate code assignment of professional charges in compliance with third-party payer and NCCI guidelines and organizational policies.
• Maintain documentation to record and track coding variances.
• Perform charge reconciliation.
• Compare hospital charges posted against procedures coded and identify any discrepancies.
• Notify leadership of discrepancies and collaborate to rectify them.
• Participate in special projects, including charge correction requests, research of payer policies, and accounts receivable and denials management.

Background & Experience

• High school diploma or equivalent, required.
• Bachelor's degree in a related field, preferred.
• Completion of college-level courses in medical terminology, anatomy and physiology, or similar, required.
• Certified Professional Coder upon hire, required.
• Certified Coding Specialist, Physician-based, upon hire, required.
• Other specialty certification such as CGSC, COSC, or CCC, preferred upon hire.
• 2 or more years of coding experience.
• Thorough understanding of health insurance and medical costs.
• Knowledge of third-party billing regulations, professional operations, and third-party payer requirements.
• Proficient computer skills, with the ability to learn internal application systems.
• Ability to communicate effectively.
• Detail-oriented, with strong organizational skills.

Reporting to clinical and coding leadership, the Coder advances accurate translation of physician documentation into ICD-10, CPT, and APC codes for professional claims, applying critical thinking to prioritize competing responsibilities. Partnering with physicians across departments, the Coder resolves complex documentation questions while adhering to HIPAA and state law requirements.

Role Responsibilities

• Problem-solve on many levels.
• Apply critical thinking and strong organizational skills to complete tasks, prioritize responsibilities, and meet required elements of the position.
• Interact with diverse staff and functions.
• Serve as a point of contact outside the department and handle a range of situations, issues, and complaints in a professional manner.
• Interpret HIPAA and state law.
• Work and interact with physicians and other healthcare personnel.

Required Qualifications

• Completion of college-level courses or relevant experience in anatomy, physiology, and medical terminology.
• Completion of a coding course in ICD-10, CPT-4, E/M, and applicable grouper coding schemes.
• Certified coder credential, such as CPC-A, CPC, or CCP.
• Ability to understand the clinical content of a health record, including the most complex records.
• Ability to work independently and prioritize workload, primarily in a home-based work environment.
• Excellent time management and prioritization abilities.

Sitting at the intersection of nursing judgment and HCC coding accuracy, the Coder oversees audits of medical records to confirm diagnosis codes match provider documentation and CMS Risk Adjustment standards. Operating across coding vendors and clinical staff, the Coder trains providers on HCC coding and analyzes MRA reports to resolve unreported conditions.

Job Functions

• Audit medical records, including consultations and diagnostic information, to ensure continuity of care.
• Review medical records via EMR or paper chart to verify the appropriateness of diagnosis and procedural codes reported by the physician and evaluate supporting documentation.
• Identify, analyze, and address documentation or coding discrepancies within the medical record.
• Arrange ongoing training for physicians, clinicians, and office staff on HCC coding, and provide education based on audit findings.
• Review and complete system-generated reports to correct or complete missing data as requested.
• Analyze MRA reports to identify and confirm unreported or unresolved medical conditions of members based on supportive medical documentation.
• Communicate the audit process and results to management, and assist senior staff with recommendations for process improvement to meet productivity and quality goals.
• Manage assigned workload efficiently and accurately while meeting deadlines and complying with HIPAA regulations.

Qualifications & Experience

• High school diploma or equivalent.
• Certified Risk Adjustment Coder certification, required.
• Registered Nurse or Licensed Practical Nurse license, required.
• 3 or more years of coding experience using ICD-10 or equivalent.
• Advanced knowledge of medical codes, terminology, abbreviations, anatomy and physiology, major diseases, pharmacology, and the metric system.