Senior Medical Records Coder — ICD-10/CPT Expert

UT Health San Antonio; San Antonio (TX); On-site; USD 55,000 - 75,000; Full time

Job summary

UT Health San Antonio is seeking a qualified coder to conduct inpatient and outpatient coding reviews under limited supervision, ensuring compliance with federal regulations and up-to-date coding guidelines. The role emphasizes accuracy in ICD-10 and CPT coding across medical records and documentation, with on-site responsibilities at the San Antonio location.

The ideal candidate has 5+ years of medical record abstraction and coding experience, strong communication skills, and the ability to

Qualifications

• Proficiency in ICD-10 and CPT coding.
• In-depth understanding of medical terminology, anatomy and physiology.
• Meticulous attention to detail and accuracy.
• Solid customer service acumen and interpersonal skills to effectively work with both internal and external customers and responds to requests in a timely and respectful manner.
• Strong verbal, written and interpersonal communication skills.

Responsibilities

• Reviews, interprets, and assigns diagnostic and procedural codes based upon medical record documentation according to correct coding principles.
• Provides skilled and specialized technical work in documentation and coding for medical billing, abstracts complex patient-related data from medical records and coding of diagnoses and procedures using ICD-10 and CPT codes.
• Works coding related charge review and claim edits daily to ensure timely and accurate billing.
• Researches and resolves coding related issues, and assists in meeting productivity and quality standards.
• Contacts other facilities to obtain medical records and information need to bill for services rendered.
• Verifies fee tickets and physician notes for completeness to include abstracting and entering relevant medical information from the medical records; checks for required signatures; assures proper documentation guidelines are followed.
• Interacts with regulator classification agencies and patients when clarification and additional information is required for documentation.
• Updates coding books with changes as accepted and published by regulatory agencies.
• Performs all other duties as assigned.

Skills

ICD-10 coding

CPT coding

Medical terminology

Attention to detail

Customer service

Communication skills

Education

High school diploma or GED

Job description

UT Health San Antonio is seeking a qualified coder to conduct inpatient and outpatient coding reviews under limited supervision, ensuring compliance with federal regulations and up-to-date coding guidelines. The role emphasizes accuracy in ICD-10 and CPT coding across medical records and documentation, with on-site responsibilities at the San Antonio location.

The ideal candidate has 5+ years of medical record abstraction and coding experience, strong communication skills, and the ability to