Job Description

General Summary

Collects, reviews, retrieves and codes data by careful review and analysis of documentation of inpatient medical records, assigning the appropriate ICD-10 codes for the purposes of compliance with regulations, statistical compilation, clinical research, clinical care analysis, provider profiling and optimal reimbursement.

Duties and Responsibilities

Essential Functions:

• Reviews entire current electronic medical record for pertinent diagnoses and procedures.
• Assigns diagnoses and procedure codes on inpatient records in accordance with established organization guidelines.
• Uses ICD-10 CM and PCS coding methodologies following Official Guidelines for Coding and Reporting using encoding software.
• Queries physicians to clarify documentation needed for coding purposes per established departmental policy.
• Performs abstraction of clinical and demographic data as pertinent to the account requirements.
• Participates in documentation improvement program using 3M software and communicating with Clinical Documentation Specialist regarding DRG assignment.
• Performs other duties that may be assigned by authorized personnel or as required to meet emergency needs of the department or Hospital.

Common Expectations:

• Maintains job specific standards and expectations relative to productivity and quality.
• Maintains established policies and procedures, objectives, quality assessment and safety standards.
• Participates in educational programs and in-service meetings.
• Maintains professional growth and development and professional credentials.
• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.

Qualifications

Minimum Education:

• High School Diploma or GED Required
• Associates Degree Preferred or
• Bachelors Degree Preferred

Work Experience:

• 3 years medical coding Required
• 3 years inpatient coding Preferred

Licenses:

• Certified Professional Coder Upon Hire Required or
• Certified Coding Associate Upon Hire Required or
• Certified Coding Specialist Upon Hire Required or
• Registered Health Information Technician Upon Hire Required or
• Registered Health Information Administrator Upon Hire Required or
• Certified Professional Coder Apprentice Upon Hire Required

Knowledge, Skills, and Abilities:

• Knowledge of ICD-10
• Knowledge of medical terminology, anatomy, and physiology
• Basic computer skills