Job Description

Responsible for abstracting and analyzing clinical information from medical records and relevant documents, translating the information into diagnostic and operative procedure codes in accordance with the clinical coding system.

• Assigns codes for diagnoses, treatments, and procedures according to the appropriate classification system outpatient (OP)/emergency department (ED) or observation short stay.

• Oversees and reviews provider documentation to determine principal diagnosis, comorbidities and complications, secondary conditions and surgical procedures.

• Adheres to official coding guidelines when coding with accuracy and completeness as supported by documentation.

• Ensures accurate coding by clarifying diagnosis and procedural information through a query process.

• Assigns Present on Admission (POA) value for inpatient diagnoses.

• Ensures accurate physician name against each service and accurate time and date.

• Interacts with physicians and other areas when additional coding information is needed; for example to prevent medical necessity denials.

• Prepares and reviews documentation to verify and when necessary, correct the patient disposition upon discharge.

• Maintains the assigned target of production and accuracy of Coding.

• Prioritizes work to ensure the timeframe of medical record coding meets regulatory requirements.

• Engages with the physicians in the Coding Query process and provides training as necessary.

• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines.

Accountabilities

• Ensures that codes are assigned correctly and sequenced appropriately as per government and insurance regulation

Experience :-

Required:

• 3 years of relevant progressive experience in a similar role.

Desired:

• Experience in a large healthcare facility

Educational Qualification: Required:

• Bachelor Degree in Health Information Management or relevant field with or Diploma with 3 years of additional experience in Healthcare

Desired:

• N.A.