Responsible for reviewing health information for a patient encounter and applying ICD-10-CM and CPT or ICD-10-CM and PCS codes in accordance with the diagnoses and treatments documented, as well as report any other pertinent information for reimbursement and research purposes.

Essential Functions and Job Duties

• Identifies and assigns appropriate codes for the purpose of reimbursement, research, and compliance in accordance with ICD-10 and CPT coding guidelines.
  • Complies with all federal, local and other legal requirements as they relate to medical coding practices.
  • Reviews all inpatient, outpatient accounts, including Emergency Department (ED), outpatient surgery and other procedures, ancillary, clinic accounts, and interventional radiology procedures and assigns and sequences all diagnoses and procedure codes to the highest level of specificity documented in the provider notes as assigned.
  • Observes confidentiality and safeguards all patient related information.
• Communicates in a positive and professional manner with visitors, physicians, and hospital staff.
  • Maintains an optimal working relationship with peers, other hospital departments, and physicians.
  • Exhibits understanding of CARES and the hospital mission statement.
  • Attends continuing education classes to maintain coding proficiency in ICD-10-CM-PCS and/or ICD-10-CM and CPT-4/HCPCS, and other areas as deemed necessary by management.
• Perform other job-related duties as required.

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. 

• Knowledge of ICD-10-CM-PCS and/or ICD-10-CM and CPT/HCPCS coding systems as assigned.
• Knowledge of medical terminology and anatomy and physiology.
• Knowledge of Outpatient Prospective Payment System (OPPS) and/or Inpatient Prospective Payment System (IPPS)
• Understanding of coding guidelines and rules for coding of injections and infusions.
• Flexibility to adjust to changes in workflow as needed to accommodate hospital volumes and census.
• Thoroughness and attention to detail.
• Ability to work independently.  

Education and/or Other Requirements

• Completion of associates degree in Health Information Management and successful completion of Registered Health Information Management (RHIT) exam; or
• Completion of bachelors degree in Health Information Management and successful completion of Registered Health Information Administrator (RHIA) exam; or
• Certified Coding Specialist (CCS) credential; or
• Certified Coding Associate (CCA) credential.
• Certified Outpatient Coding (COC) credential will be considered if candidate is willing to obtain an American Health Information Management (AHIMA) credential within 6 months of hire.
• Two (2) years of coding experience.
• Experience in outpatient interventional radiology procedures preferred.
• Charge capture experience, preferred. 

In addition to the Essential Functions and Qualifications listed above, to perform the job successfully an individual must also possess the following General Skill Requirements.

• Adaptability – Adapts to changes in the work environment; Manages competing demands; Accepts criticism and feedback; Changes approach or method to best fit the situation; ability to work with frustrating situations; work under pressure and on an irregular schedule such as unscheduled overtime, unanticipated changes in work pace; Works with numerous distractions.
• Attendance and Punctuality – Schedules time off in advance; Begins working on time; Keeps absences within guidelines; Ensures work responsibilities are covered when absent; Arrives at meetings and appointments on time.
• Communications – Expresses ideas and thoughts verbally; Expresses ideas and thoughts in written form; Exhibits good listening and comprehension; Keeps others adequately informed; Selects and uses appropriate communication methods.
• Cooperation – Establishes and maintains effective relations; Exhibits tact and consideration; Displays positive outlook and pleasant manner; Offers assistance and support to co-workers; Works cooperatively in group situations; Works actively to resolve conflicts.
• Job Knowledge – Competent in required job skills and knowledge; Exhibits ability to learn and apply new skills; Keeps abreast of current developments; Requires minimal supervision; Displays understanding of how job relates to others; Uses resources effectively.
• Judgment – displays willingness to make decisions; Exhibits sound and accurate judgment; Supports and explains reasoning for decisions; Includes appropriate people in decision-making process; Makes timely decisions; ability to work with and maintain confidential information.
• Problem solving – Identifies problems in a timely manner; Gathers and analyzes information skillfully; Develops alternative solutions; Resolves problems in early stages; Works well in group problem solving situations.
• Quality – Demonstrates accuracy and thoroughness; Displays commitment to excellence; Looks for ways to improve and promote quality; Applies feedback to improve performance; Monitors own work to ensure quality.
• Quantity – Meets productivity standards; Completes work in timely manner; Strives to increase productivity; Works quickly; Achieves established goals.
• Concentration – Maintains attention to detail over extended period of time; continually aware of variations in changing situations.
• Supervision – ability to perform work independently or with minimal supervision; ability to assign and/or review work; train and/or evaluate other employees.