| Job Category |  | Office & Administrative Support |
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| Job Description | | A medical coding (or clinical coding) specialist is an individual who reviews and analyzes health records to identify relevant diagnoses and procedures for distinct patient encounters. The medical coding specialist is responsible for translating diagnostic and procedural phrases used by healthcare providers into coded form. The translation process requires interaction with the healthcare provider to ensure that the terms have been translated correctly. The coded information that is a product of the coding process is then used for reimbursement purposes, in the assessment of clinical care, to support medical research activity and to support the identification of healthcare concerns critical to the public at large.
The medical coding specialist must have a thorough understanding of the content of the medical record to be able to locate information to support or provide specificity for coding. The medical coding specialist works as part of a team to achieve the best quality patient care.
Job titles include clinical coding specialist, clinical data specialist,
data quality manager and health information management (HIM) compliance specialist .
The clinical coding specialist applies the appropriate diagnostic and procedural codes to individual patient health information for data retrieval, data analysis, and claims processing.
The clinical data specialist is a member of the data management team responsible for ensuring the accuracy and completeness of clinical coding validating the information in the databases for outcomes management and specialty registries and performing clinical research across the entire integrated healthcare system.
The data quality manager is responsible for developing, implementing, and maintaining a data quality management (compliance) plan for coding and reimbursement, health records and documentation, and quality data in all divisions of the organization.
The HIM compliance specialist oversees and monitors implementation of the HIM compliance program in the organization. |
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| Working Conditions | | While hospitals are the primary work setting for coders, they are also found in physicians' offices, as consultants, in healthcare delivery systems, and in long term care and ambulatory care settings.
According to the Occupational Outlook Handbook (OOH), medical records and health information technicians usually work a 40-hour week. Some overtime may be required in hospitals—where health information departments often are open 24 hours a day, 7 days a week—technicians may work day, evening, and night shifts.
Medical records and health information technicians work in pleasant and comfortable offices. This is one of the few health occupations in which there is little or no direct contact with patients. Because accuracy is essential in their jobs, technicians must pay close attention to detail. |
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| Salary Range | | According to the AHIMA, the average salary for coders by setting is as follows:
Ambulatory Care, $43,262
Behavioral/Mental Health, $33,777
Consultant/Vendor, $58,488
Educational Institution, $40,522
HIM Specialty Setting, $46,007
Hospital, $44,064
Integrated Healthcare Delivery System, $45,297
Long-term Care, $39,084
Nonprovider Setting, $44,610
Physician Office, $43,995 |
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