Job description
Job DescriptionProcesses medical records by coding, abstracting data and producing information for third party billing and to provide a complete statistical data base.
Demonstrate respect, dignity, kindness and empathy in each encounter with all patients, families, visitors and other employees regardless of cultural background.
Job Duties
Reviews inpatient or observation, same day surgery, and interventional procedure records, identifies and codes principal and secondary diagnoses and principal and secondary procedures in appropriate sequence so that the accurate DRG/APC will be assigned according to Official Coding Guidelines to provide information for billing purposes. Meets department coding standards for quality and productivity of 96%. New staff are expected to meet these standards upon completion of the training period.
Assigns all codes based on documentation. Participates in corporate compliance program. Upholds the highest ethical standards.
Abstracts demographic and medical information into abstracting software following departmental guidelines to provide for accurate database for statistical reference.
Completes various reports such as productivity reports, statistical reports and log sheets in order to maintain an accurate source of reference material and other documentation. Performs daily or weekly follow-up of all dates assigned and submits updates accordingly.
Communicates with Corporate Coding Manager, Coding Team Leader, CDI Specialists, Patient Accounts staff and fellow coders in a professional manner as needed regarding held accounts, coding changes, physician queries, rebills, etc.
Attends educational programs and applies knowledge to enhance job performance. Uses resources available for accurate coding (i.e. Coding Clinic and CPT Assistant).
Performs other duties as assigned.
Qualifications
Education, Credentials, Licenses:
- Associate or Bachelor’s degree (or equivalent hospital based coding experience.
- CCS, CPC-H, RHIT, RHIA credentials
- Physician coding credentials CCS-P and CPC are not preferred but recognized for coding other than inpatient.
- An apprentice credential is not sufficient.
Medical Terminology, Anatomy and Physiology, ICD/CPT experience, Prospective Payment Systems, Outpatient Medical Necessity, use of personal computer.
Kind and Length of Experience:
Five years hospital coding experience.
Proven verbal and written communication skills
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