The Coder reviews patient records and assigns codes (ICD-10-CM, ICD-10-PCS, CPT, HCPCS) for each diagnosis and procedure. The coder applies knowledge of medical terminology, disease processes, and pharmacology to ensure these codes accurately reflects the care provided to each patient. RESPONSIBILITIES (ESSENTIAL FUNCTIONS): Accurately assigns and sequences codes (ICD-10-CM, ICD-10-PCS, CPT, HCPCS) for each patient encounter, following proper coding guidelines and legal requirements to ensure compliance with federal and state regulations. Abstracts required medical record information from patient records. Ensures correct diagnosis related group (DRGs), all patient refined diagnosis related groups (APR DRGs), and ambulatory payment classification (APCs) are calculated. Queries providers when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes. Assigns and enters charges such as evaluation and management (E&M) levels, infusion/injections, observation hours, etc. Participate in continuing education activities to expand coding skills and stay abreast of changes in coding guidelines and reimbursement reporting requirements. Foster positive working relationships with Clinical Documentation Integrity (CDI), billing, and other pertinent positions at DRH Health. Identifies and reports discrepancies, potential quality concerns, and billing issues. Reviews records to ensure documentation in the record supports ordered services and meets medical necessity. Abides by the Standards of Ethical Coding as set forth by the American Health Information Association and adheres to official coding guidelines. Distribute confidential and sensitive information or documentation; Handle highly confidential records. Ensure records are safe and secure at all times. Regular attendance and punctuality for scheduled shifts. Maintains professional and technical knowledge through continuing education opportunities including internal and external educational offerings. Utilization of assistive devices for lifting is mandatory. Must adhere to safety protocols at all times. Per DRH policy, all required conditions of employment must be met and maintained including required vaccinations. Implement DRH Standards of Behavior and exhibit behaviors consistent with DRH core values. Performs other related duties as assigned. Minimum Qualifications: Outstanding communication and interpersonal skills including fluency in oral and written English. Basic computer skills including the ability to send/receive/email, navigate information technology associated with the position, and use Electronic Health Record information tools. Strong attention to detail with excellent organizational skills. Ability to adapt procedures, processes, tools, equipment, and techniques to accomplish the requirements of the position. Education and/or Experience: High school diploma or equivalent required. Associate or bachelor's degree in Health Information Management is preferred. Previous work experience as a coder or strong training background in coding and reimbursement required. Prefer at least 3 years of experience in DRG and/or APC assignment. Certifications, Licenses, Registrations: Registered Health Information Administrator (RHIA) certification or Registered Health Information Technician certification (RHIT) preferred. CCS or CPC preferred. For those positions requiring travel, a current valid drivers license and automobile liability insurance must be maintained. Non Safety-Sensitive Position As a condition of employment, vaccinations are required per DRH Policy. Medical and Religious Exemptions are available upon request.