Job Description

Job Description

Job Description

REQUIREMENTS:

• License/Certification: Must possess one of the following AAPC/AHIMA certifications: Certified Inpatient Coder (CIC), Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA)
• Experience: Minimum of 1-2 years’ experience as an Inpatient Coder at an acute care or academic teaching facility required or successful completion of Inpatient Coding apprenticeship program.
• Proficiencies: Extensive knowledge of medical terminology, anatomy and physiology, pathophysiology, pathology and laboratory medicine, coding guidelines for ICD-10, CM, PCS, CPT, Modifiers, etc.
• Knowledge of legal, regulatory, and policy compliance issues related to medical coding and billing procedures, and documentation including CMS guidelines.
• Proficient computer skills using MS-Word, Excel, PowerPoint, Outlook, Electronic Medical Records (EMR) systems including Paragon, eClinical Works, Computer Assisted Coding (CAC)

RESPONSIBILITIES:

• Reviews medical records to identify diagnoses, CPT procedures and PCS procedures relative to the patient’s encounter.
• Selects the principal diagnosis and principal procedure, along with other diagnoses and procedures using UHDDS definition. Ensures appropriate DRG assignment.
• Abstracts appropriate information from the medical record based on the guidelines provided by the hospital and after a thorough review of the medical record.
• Solicits clarification from the physician regarding ambiguous or conflicting documentation in the medical record using guidelines provided by the hospital.
• Ensure all coding complies with the ethical coding standards/guidelines and regulatory requirements.

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