Clinical Coder - General Radiology

Job Overview

The Clinical Coder for General Radiology is responsible for reviewing hospital medical records, interpreting clinical documentation, and assigning the correct ICD-10-CM diagnosis and CPT procedure codes where relevant. The role focuses on ensuring that records are complete, accurate, and properly abstracted, while using 3M Coding Reimbursement tools and other reference resources to support code selection and data compilation.

This position handles coding for multiple specialties and may also involve supporting, mentoring, and training other coding team members. It requires the use of encoder systems and online references, validation of charges against clinical documentation, and an understanding of how diagnoses should be linked to procedures when applicable. The role also includes reviewing retrospective edits to identify and resolve possible coding or documentation issues, and working with CDI specialists, physicians, and other healthcare professionals to clarify unclear or conflicting information. In addition, the Clinical Coder collaborates with Revenue Cycle Management teams to help address billing and utilization concerns that affect reimbursement.

Responsibilities

• Review clinical records and apply the correct diagnostic, treatment, and procedure codes for inpatient, outpatient, emergency, and observation cases as applicable.
• Assess physician documentation to identify the main diagnosis, coexisting conditions, complications, secondary diagnoses, and procedures, including E&M services.
• Follow official coding standards and ensure the coded record is both accurate and complete.
• Use the query process to resolve unclear or missing diagnosis and procedure details.
• Assign the Present on Admission indicator for inpatient diagnoses where required.
• Record the correct physician name, service date, and time for each coded service.
• Communicate with physicians and relevant departments when additional details are needed to avoid medical necessity denials.
• Check discharge documentation and make corrections to patient disposition when needed.
• Work toward assigned productivity and accuracy goals for coding output.
• Organize coding workload so records are completed within regulatory timeframes.
• Participate in coding queries with physicians and provide training support when necessary.
• Follow AHIMA ethical coding standards and applicable coding guidelines.
• Prepare reports and statistics as requested by management.
• Take on other related duties as assigned.
• Manage pressure effectively and handle several tasks simultaneously.
• Help maintain a constructive and supportive work environment.
• Work cooperatively with team members to ensure smooth operations.
• Ensure code assignment and sequencing align with government and insurance requirements.
• Apply suitable methods and strategic approaches to achieve accurate results.

Requirements

• 2 to 4 years of relevant, progressive experience in a similar position.
• Prior experience in a large healthcare facility is preferred.
• Bachelor’s degree in Health Information Management or a related discipline, or a diploma plus 3 additional years of healthcare experience.
• A master’s degree or equivalent in Health Information Management or a related field is preferred.

Additional Information

This role requires strong attention to detail, the ability to work across multiple specialties, and comfort using coding software, retrospective edit tools, and online reference materials. It also involves supporting reimbursement accuracy, documentation clarification, and collaboration with clinical and revenue teams.

Terms and Conditions

All coding activity must comply with official coding guidance, AHIMA ethical standards, and applicable government and insurance regulations.