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Clinical Coder (Full Time/ Day)


Full time position, flexible schedule, no on-call, holidays or weekends. LGH HIM department, allows for flexibility in scheduling to accommodate busy lifestyles. Once Data Quality and Productivity are acceptable, remote location can be used.

Job Description

POSITION SUMMARY: : Codes and abstracts information from inpatient and outpatient records by careful analysis and adherence to official coding guidelines assuring appropriate reimbursement, compliance with regulations, and accuracy for clinical care analysis and provider profiling.

ESSENTIAL FUNCTIONS: Qualified individuals must have the ability (with or without reasonable accommodation) to perform the following duties:

  • Demonstrates commitment to the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA).  Assigns codes based upon clinical coding guidelines.

  • Assigns ICD-10-CM diagnostic, procedure codes with appropriate present on admission indicators to inpatient records, based upon the practitioner clinical documentation.  Determines appropriate MS-Diagnostic Related Group (DRG) based upon diagnoses and procedure codes assigned. 

  • Assigns ICD-10-CM diagnostic and CPT procedure codes and modifiers to outpatient accounts.  

  • Applies drug administration charges to outpatient accounts based on the clinical documentation and guidelines.

  • Applies observation hour charges to observation accounts based on the clinical documentation and guidelines.

  • Reviews and appropriately applies modifiers to the NCCI (National Correct Code Initiative) and OCE (Outpatient Code Edits).    

  • Abstracts required clinical and demographic data from inpatient and outpatient records.

  • Participates in data quality peer review process, reviewing records according to established procedure.

SECONDARY FUNCTIONS: The following duties are considered secondary to the primary duties listed above:

  • Assists Patient Financial Services and physician offices with coding—related issues.

  • Completes a productivity record on a daily basis and submits to Clinical Coding Supervisor on a weekly basis
  • Assists with appropriate capture of inpatient case mix.



  •  High school diploma or equivalent (GED).
  • Formal education in ICD-10-CM/PCS and CPT-4 coding, medical terminology, anatomy and physiology.
  • Certification as a Certified Coding Specialist (CCS) or Certified Coding Specialist-Physician (CCS-P) through AHIMA (American Health Information Association), or certified by AAPC (American Association Professional Coders) with certification as a Certified Professional Coder (CPC), or Certified Professional Coder-Hospital Outpatient (COC).  If not certified, coding certification is required within three (3) years of employment. 
  • Experience in ICD-10-CM/PCS coding/MS-DRG assignment (this may include student work experience) Experience in CPT-4 coding (this may include student work experience)


  • Some experience with encoding software.

Disclaimer: This job description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills, efforts, or working conditions associated with the job.  It is intended to be a reflection of those principal job elements essential for recruitment and selection, for making fair job evaluations, and for establishing performance standards.  The percentages of time spent performing job duties are estimates, and should not be considered absolute.  The incumbent shall perform all other functions and/or be cross-trained as shall be determined at the sole discretion of management, who has the right to amend, modify, or terminate this job in part or in whole.  Incumbent must be able to perform all job functions safely.

Benefits At A Glance:

PENN MEDICINE LANCASTER GENERAL HEALTH offers the following benefits to employees:

  • 100% Tuition Assistance at The Pennsylvania College of Health Sciences
  • Paid Time Off and Paid Holidays
  • Shift, Weekend and On-Call Differentials
  • Health, Dental and Vision Coverage
  • Short-Term and Long-Term Disability
  • Retirement Savings Account with Company Matching
  • Child Care Subsidies
  • Onsite Gym and Fitness Classes


PENN MEDICINE LANCASTER GENERAL HEALTH is an Equal Opportunity Employer, committed to hiring a diverse workforce. All openings will be filled based on qualifications without regard to race, color, sex, sexual orientation, gender identity, national origin, marital status, veteran status, disability, age, religion or any other classification protected by law.


Search Firm Representatives please read carefully: PENN MEDICINE LANCASTER GENERAL HEALTH is not seeking assistance or accepting unsolicited resumes from search firms for this employment opportunity. Regardless of past practice, all resumes submitted by search firms to any employee at PENN MEDICINE LANCASTER GENERAL HEALTH via-email, the Internet or directly to hiring managers at Penn Medicine Lancaster General Health in any form without a valid written search agreement in place for that position will be deemed the sole property of PENN MEDICINE LANCASTER GENERAL HEALTH, and no fee will be paid in the event the candidate is hired by PENN MEDICINE LANCASTER GENERAL HEALTH as a result of the referral or through other means.

MILL Full Time Posted on 02/24/2023