What Does a Medical Coder Do?
A medical coder is responsible for reviewing clinical documentation and translating it into standardized medical codes used for billing, insurance reimbursement, and health data tracking. These codes, such as ICD-10, CPT, and HCPCS, represent diagnoses, treatments, and procedures documented by healthcare providers. Coders work with physicians, nurses, and administrative teams to ensure that all services are captured accurately and in compliance with regulatory standards.
Medical coders are essential to the financial and legal integrity of healthcare organizations. By applying detailed knowledge of medical terminology, anatomy, and payer-specific guidelines, coders help maximize appropriate reimbursement while reducing the risk of claim denials, audits, and legal issues. Their work impacts everything from patient billing accuracy to public health reporting and quality assurance.
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Medical Coder Core Responsibilities
- Review clinical documentation for accuracy and completeness
- Assign ICD-10, CPT, and HCPCS codes for diagnoses, treatments, and procedures
- Abstract relevant patient information from EHRs and physician notes
- Ensure coding aligns with insurance, Medicare, and regulatory guidelines
- Query providers for clarification as needed
- Work with billing teams to resolve claim rejections or denials
- Maintain up-to-date knowledge of coding changes and payer rules
- Adhere to HIPAA and organizational privacy standards
Required Skills and Qualifications
Hard skills
- Proficiency in ICD-10-CM, CPT, and HCPCS Level II coding
- Familiarity with EHR systems and encoder software (e.g., 3M, TruCode)
- Knowledge of medical terminology, anatomy, and physiology
- Understanding of payer policies and billing compliance
Soft skills
- High attention to detail and accuracy
- Analytical thinking and problem-solving
- Ability to work independently and meet deadlines
- Effective written communication for queries and documentation
Education
- High school diploma or equivalent
- Completion of a medical coding training program or associate’s degree in health information management
Certifications
- Required or strongly preferred depending on employer:
- Certified Professional Coder (CPC – AAPC)
- Certified Coding Specialist (CCS – AHIMA)
- Certified Coding Associate (CCA – AHIMA)
- Recommended: HIPAA training and compliance coursework
Preferred Qualifications
- 1–3 years of coding experience in outpatient, inpatient, or specialty care settings
- Experience working with multiple payers (Medicare, Medicaid, commercial insurers)
- Exposure to risk adjustment, HCC coding, or audit-prevention practices
National Average Salary
Compensation for medical coders will vary based on experience, geographic location, and certifications. Working for larger healthcare systems or specializing in specific medical fields can also impact pay rates. Click below to explore salaries by local market.
The average national salary for a Medical Coder is:
$46,500
Sample Job Description Templates for Medical Coders
Entry-Level Medical Coder
Position Overview
We are seeking an Entry-Level Medical Coder to support our revenue cycle and health information management team. This position is ideal for a recent graduate or trainee ready to apply foundational coding knowledge in a clinical or outpatient setting. Under the guidance of senior coders, you will assist with reviewing documentation and applying appropriate medical codes for billing and recordkeeping.
Responsibilities
- Review clinical notes and assign basic ICD-10 and CPT codes
- Abstract and enter patient information into EHR and billing systems
- Flag incomplete documentation and escalate queries to supervisors
- Support claims preparation and assist in correcting basic coding errors
- Stay current on changes to coding standards and payer guidelines
Requirements
Hard skills
- Familiarity with ICD-10-CM, CPT, and HCPCS coding systems
- Basic understanding of anatomy, physiology, and medical terminology
- Exposure to EHR platforms or encoder tools (school or internship)
Soft skills
- High attention to detail and accuracy
- Ability to follow instructions and standard workflows
- Good written communication for coding notes or queries
Education
- High school diploma or equivalent
- Completion of an accredited medical coding program
Certifications
- Not required
- Preferred: CCA (AHIMA), CPC-A (AAPC), or equivalent entry-level credential
Preferred Qualifications
- Internship or practicum experience in a clinical or outpatient environment
Certified Medical Coder
Position Overview
We are hiring a Certified Medical Coder to join our health information team. The ideal candidate is credentialed and experienced in coding outpatient, specialty, or procedural encounters. You’ll be responsible for ensuring claims are accurate, compliant, and submitted promptly to support optimal reimbursement.
Responsibilities
- Assign ICD-10, CPT, and HCPCS codes to diagnoses and procedures
- Review provider documentation and abstract relevant clinical information
- Apply coding edits and modifiers to meet payer and regulatory requirements
- Query providers for clarification when documentation is incomplete
- Collaborate with billing and audit teams to resolve denials
Requirements
Hard skills
- Proficiency with EHR and encoder software (e.g., 3M, TruCode, Epic)
- In-depth knowledge of coding guidelines and payer rules
- Strong understanding of medical terminology and anatomy
Soft skills
- Analytical thinking and pattern recognition
- Clear written communication for documentation queries
- Organized and deadline-driven
Education
- Completion of a formal medical coding or health information program
Certifications
- Required: CPC (AAPC), CCS or CCA (AHIMA), or equivalent
Preferred Qualifications
- 1–2 years of experience in outpatient or specialty coding
Senior Medical Coding Specialist
Position Overview
We are looking for a Senior Medical Coding Specialist to perform advanced coding duties, audit complex records, and mentor junior coders. This role requires expert knowledge in diagnostic and procedural coding, documentation interpretation, and compliance best practices.
Responsibilities
- Code high-complexity charts across multiple specialties or care settings
- Identify documentation gaps and assist providers with improvement feedback
- Review and audit peer coding for accuracy and compliance
- Assist in appeal preparation for denied claims
- Train and support new coding staff and interns
Requirements
Hard skills
- Mastery of ICD-10, CPT, HCPCS Level II, and modifier use
- Familiarity with coding audits, CDI, and payer-specific rules
- Proficiency in risk adjustment or procedural coding (e.g., surgery, cardiology)
Soft skills
- Strong critical thinking and auditing mindset
- Excellent written communication for queries and feedback
- Collaborative and mentoring-focused approach
Education
- Associate’s degree or higher in health information management or related field
Certifications
- Required: CPC, CCS, or equivalent advanced credential
- Recommended: CRC (AAPC), CDIP (AHIMA)
Preferred Qualifications
- 4+ years of medical coding experience, including complex chart types
Lead Medical Coder
Position Overview
We are hiring a Lead Medical Coder to oversee day-to-day coding operations, ensure quality standards, and support workflow coordination across clinical departments. This role is responsible for guiding coders, providing expert review of documentation, and maintaining compliance across all coding functions.
Responsibilities
- Oversee and prioritize daily coding workload across the team
- Perform high-level coding reviews and secondary audits
- Develop and update coding guidelines and documentation templates
- Mentor coding staff and assist with ongoing education
- Liaise with providers to address recurring documentation issues
- Report on coding accuracy, denial trends, and productivity metrics
Requirements
Hard skills
- Advanced knowledge of medical coding principles, regulatory guidelines, and reimbursement models
- Experience with EHR integration and process optimization
- Strong command of medical specialties and multi-payer billing practices
Soft skills
- Leadership and team coordination
- Analytical skills and attention to regulatory compliance
- Effective communication across clinical and non-clinical teams
Education
- Associate’s degree in health information or healthcare administration preferred
Certifications
- Required: CPC, CCS, or equivalent
- Recommended: CDIP, CRC
Preferred Qualifications
- 5+ years of coding experience, with 1–2 years in a lead or training role
Medical Coding Supervisor
Position Overview
We are seeking a Medical Coding Supervisor to manage a team of coders, oversee coding operations, and ensure compliance with industry standards and organizational goals. This leadership role balances technical expertise with workflow optimization and staff development.
Responsibilities
- Supervise medical coding staff and assign daily work priorities
- Monitor KPIs related to coding accuracy, timeliness, and productivity
- Lead regular audits and ensure adherence to HIPAA and regulatory standards
- Coordinate training programs and continuing education initiatives
- Collaborate with HIM, billing, compliance, and clinical documentation teams
- Analyze denial patterns and implement corrective strategies
Requirements
Hard skills
- Strong knowledge of coding systems, reimbursement policy, and regulatory compliance
- Experience managing teams and developing SOPs
- Familiarity with audit tools, data reporting, and performance metrics
Soft skills
- Strategic planning and decision-making
- Mentorship and team-building skills
- Excellent communication and process management
Education
- Associate’s or bachelor’s degree in HIM, healthcare administration, or related field
Certifications
- Required: CPC, CCS, or equivalent
- Recommended: CDIP, CRC, or RHIT
Preferred Qualifications
- 6+ years of coding experience with at least 2 in a supervisory or lead role