York, PA | Clerical and Administrative | Tracking Code: 64325

Job Description:

Under the direct supervision of the Supervisor-Coding, collects, reviews, retrieves and codes data by careful review and analysis of documentation of inpatient medical records, assigning the appropriate ICD-9-CM/ICD-10-CM and CPT codes for the purposes of compliance with regulations, statistical compilation, clinical research, clinical care analysis, provider profiling and optimal reimbursement.


Duties and Responsibilities

Essential Accountabilities:

  1. Reviews patients' entire current electronic and/or paper medical record for pertinent diagnoses and procedures.
  2. Assigns diagnoses and procedure codes on inpatient records in accordance with established organization guidelines.
  3. Uses ICD-9/ICD-10 and CPT coding methodologies following Official Guidelines for Coding and Reporting using encoding software.
  4. Queries physicians to clarify documentation needed for coding purposes per established departmental policy.
  5. Performs abstraction of clinical and demographic data as pertinent to the account requirements.
  6. Participates in documentation improvement program using CDMP Guide software and communicating with Clinical Documentation Nurse regarding DRG assignment.
  7. Performs compliance self-review of each coded record using compliance software including reviewing edits, tips, etc..
  8. Performs other duties that may be assigned by authorized personnel or as required to meet emergency needs of the department or Hospital.



  • Minimum Experience:
    • 3 years
  • Minimum Education:
    • High School or G.E.D.
  • Preferred Education:
    • Associate’s or Bachelor’s Degree
  • Required Certification:
    • Certified Procedural Coder CPC); or Certified Coding Specialist (C.C.S.)
  • Skills:
    • Knowledge of ICD-9, ICD-10 and CPT coding; knowledge of medical terminology, anatomy and physiology; basic computer skills
Similar Opportunities

Why WellSpan Health?

WellSpan Health is an integrated health system that serves the communities of central Pennsylvania and northern Maryland. The organization comprises a multispecialty medical group of more than 1,600 physicians and advanced practice providers, a regional behavioral health organization, a home care organization, eight respected hospitals, more than 20,000 employees and 200 patient care locations. WellSpan is a charitable, mission-driven organization committed to exceptional care for all, lifelong wellness and healthy communities. We are committed to transforming the health of the communities we serve and to educating the next generation of clinicians, staff and leaders.

Employment Benefits

  • Sign-on incentives for new employees (click here for details)
  • Medical, dental and vision insurance
  • Life and accidental death insurance
  • Supplemental life insurance
  • Retirement savings plan
  • Paid time off (PTO)
  • PTO bridging
  • Short-term disability
  • Educational assistance
  • Forgivable loan
  • Flexible spending
  • Credit union
  • Employee recreational activities
  • Childcare
  • Complimentary medicine discounts

Diversity & Inclusion

Welcome. Respect. Value.

Wellspan Health believes that diversity includes all the human characteristics that make each of us similar as well as different. We strive to make every person feel welcomed, respected, and valued while creating a safe and inclusive environment where we all have the individual freedom to express our uniqueness in a respectful manner.

WellSpan Health is an equal opportunity employer. Employment selection and related decisions are made without regard to sex, race, age, disability, religion, national origin, color or any other protected class. WellSpan Health does, however, have a tobacco-free/nicotine-free hiring policy.

Quality of Life

Founded in 1741, the city of York is considered by many as the first capital of the United States. The Articles of Confederation were signed by the Second Continental Congress here in 1777. Its beautifully restored historic district is an architectural treasure. While York retains its farming and manufacturing heritage, at its heart York is a thriving cultural community that has attracted creative talent and innovative entrepreneurial investors from across the nation.

Life in York County offers affordable housing, options for higher education, a thriving arts and cultural community, historical attractions, parks and recreational resources, semi-professional baseball team, fine dining and more — within an easy drive of major East Coast cities.

York County residents can find local employment in healthcare, manufacturing, technology, agricultural and service sectors. (Patient population: 445,000)