Position Summary

The Clinical Records and Coding Coordinator is responsible for compiling, processing, and maintaining patient medical records. You will translate complex clinical documentation into universal diagnostic and procedural codes (such as ICD-10, CPT, and HCPCS) to facilitate accurate insurance claims and maintain strict adherence to regulatory compliance and privacy standards.

Key Responsibilities

Coding & Abstracting

Review and analyze provider notes, and treatment records to accurately assign clinical codes for diagnoses and procedures.

• Ensure all codes follow accepted conventions, guidelines, and medical necessity standards.
• Audit coded data to validate that the clinical documentation perfectly supports the services rendered.

Records Management & Security

• Validate and enter patient health information into Electronic Health Records (EHR) systems.
• Monitor patient records for timeliness, completeness, and accuracy.
• Ensure the physical and electronic security of medical records, rigorously enforcing HIPAA and other patient privacy regulations.
• Process admission and discharge documents and manage the release of information to authorized personnel.

Provider Collaboration & Training

• Act as a subject matter expert and liaison between clinical staff and the billing department.
• Work with APPs and staffing agencies to clarify missing, conflicting, or unclear documentation.
• Provide ongoing training and educational updates to providers regarding evolving coding guidelines and documentation requirements.

Qualifications & Skills

• Education: Associate's or Bachelor’s degree in Health Information Management, Healthcare Administration, or a related field.
• Experience: 2–4 years of medical coding and health information management experience.
• Certifications: Active certification such as Certified Coding Specialist (CCS) through AHIMA or Certified Professional Coder (CPC) through AAPC.
• Technical Proficiency: High familiarity with EHR systems, medical coding software, and Google Workspace.
• Soft Skills: Exceptional attention to detail, strong analytical capabilities, and excellent communication skills.