Responsible for coding hospital outpatient and/or inpatient records for the purpose of reimbursement, research, and education in compliance with federal, state and regulatory agencies’ guidelines using the most current ICD-10-CM/PCS, CPT-4/HCPCS and Medicaid classification systems.  Assists in development of quality monitors and provides training to new coders as needed.

Education and/or Other Requirements

• Bachelor’s degree with successful completion of CCS credential
• Bachelor’s degree in Health Information Management with successful completion of the Registered Health Information Management Administrator (RHIA) exam or; 
• Associates degree in Health Information Management with successful completion of the Registered Health Information Technician (RHIT) exam; and/or 
• Certified Coding Specialist (CCS) credential.
• Minimum of 3 years’ experience in inpatient setting for inpatient coding or coding services in an acute care setting, including but not limited to ICD-10-CM/PCS and CPT-HCPCs coding skills. 
• Epic system and 3M encoder experience preferred. 
• Charge capture experience preferred
• Three (3) years of inpatient coding at a Level I or II trauma center preferred.
• Interventional radiology coding experience preferred.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required. 

• Must have thorough knowledge of ICD-10-CM/PCS and CPT/HCPCS coding. 
• Knowledge of medical terminology, anatomy & physiology, DRG and APC assignment. 
• Extensive knowledge of pertinent reimbursement systems, including, but not limited to inpatient prospective payment system, and outpatient prospective payment system. 
• Excellent analysis, communication, and decision-making skills.
• Organized and attention to detail and quality.
• Ability to perform computer functions in Microsoft Windows. 
• Ability to work as a team member without direct supervision.

Environmental Factors

Occasional exposure to moderate environmental variations, above-normal noise levels, and/or unpleasant substances.  Exposure to hazardous or potentially injurious elements or conditions is limited.

Physical Demands

The physical demands described are representative of those that must be met by an employee to successfully perform the essential functions of this job.

• Extensive use of keyboard, mouse, and monitor.
• Occasional business-related travel might be required.
• Little or no physical effort or strenuous activity other than incidental walking, standing, bending and reaching and carrying of light loads (1 to 5 pounds).

Mental Demands

• Analyze information or data.
• Ability to adjust to performing routine and repetitive tasks without specific supervision.
• Ability to understand and relate to the concepts behind specific ideas and remember multiple tasks given to self and others over long periods of time.
• Comprehend written basic instructions, and office memoranda.
• Ability to adhere to strict confidentiality requirements.
• Ability to communicate in oral and written form using advanced level of vocabulary.

• Identifies and codes hospital all outpatient and/or inpatient records for the purpose of reimbursement, research, and compliance according to documented diagnosis(es) operation(s) and procedure(s).  Abstracts all required information in accordance with national and facility requirements.  
  • Accurately extracts clinical information from records according to established requirements using abstracting software. 
  • Meets established quality (95% DRG accuracy) and productivity (2.5 records/hr. average) standards.
  • Understands and keeps abreast of Medicare regulations that relate to coding and DRG validation and APC guidelines.
  • Interpret coding rules and general policies in addition to determining appropriate conclusions. 
  • Must be able to explain codes, terminology and coding guidelines to physicians and hospital personnel.
  • Observes confidentiality and safeguards all patient related information.
• Works with Clinical Documentation Improvement (CDI) staff to ensure complete, consistent documentation within the medical record.
  • Identifies documentation that requires clarification.
  • Works with CDI team, Coding Coordinator and/or Coding Supervisor to resolve differences between CDI and Coding.   
• Assists the Coding Supervisor and/or Coding Coordinator with the development and/or revision of policies as requested. 
  • Assist with mentoring of coding staff when requested by the Coding Supervisor and/or Coding Coordinator.
• Communicates a positive, professional manner in contacts with visitors, physicians, and hospital staff.
  • Attends continuing education classes to maintain coding proficiency in ICD-10-CM/PCS, CPT/HCPCS, ambulatory surgery, ambulatory care and other areas as deemed necessary by management.
  • Exhibits understanding of CARES and hospital mission statement.
  • Maintains a good working relationship within the department, hospital departments and with medical staff.
• Perform other job-related duties as required.