CODING SPECIALIST
Reviews electronic medical record documentation to obtain or verify diagnoses and procedures.Assigns accurate ICD-9 and CPT codes utilizing an electronic encoder application in accordance with hospital policy and regulatory body guidelines.Performs accurate, optimal DRG and APC assignment, in accordance with nationally established rules and guidelines based upon documentation within the medical record.Reviews electronic medical record documentation and abstracts statistical data into HIS abstracting system based upon hospital policy and regulatory body guidelines.Assists with quality assurance (peer) reviews to ensure data integrity and accuracy of coding, identifies opportunities for improvements, and makes recommendations for optimal enhancements.Assists with training of new coder, when needed.Assists Case Management and Patient Access Departments in providing appropriate CPT codes for preadmission and pre-certification requirements.Provides assistance to Clinical Documentation Management Program (CDMP) with appropriate DRG assignment, diagnoses and procedures sequencing, and coding and documentation training.Aggregates data from reviews and compiles reports for HIM MgmtCommunicates as necessary with physicians to obtain or clarify diagnoses and/or procedures via the internal physician query process and making sure the physician documents within the medical record.Maintains data integrity of coded and abstracted records within 95% accuracy.Verifies accuracy of transcribed reports/indexed documents and assigns errors to the appropriate queue in the electronic medical record application.Meets minimum coding productivity standards within 3 months of employment or maintains minimum coding productivity standards during employment while ensuring accuracy of coding. Represents the coding area in the hospital meeting/events when necessary.Performs other job related duties as assigned.Demonstrates components of ICARE value statement.Demonstrates components of ServicePRIDE standards.Follow all safety rules while on the job. Experience Certified Coding Specialist (CCS) required.Registered Health Information Technology (RHIT) required with 10+ years inpatient coding experience in an acute-care setting with minimum 2 years coding experience in a 200+ bed, acute-care facility. OrRegistered Health Information Administrator (RHIA) required with 7+ years inpatient coding experience in an acute-care setting with minimum 2 years coding experience in a 200+ bed, acute-care facility.