Job Summary
Under the general supervision of Manager and direct supervision of Supervisor, following established policies, procedures and professional guidelines, the Coder 1 will :
- Perform a thorough review of medical record documentation to accurately assign diagnosis and procedure codes.
- Utilize the encoder system to sequence the codes assigned and calculate the corresponding MS-DRG / APR DRG / APC grouper.
- Abstract patient information into the computerized medical record and billing systems, ensuring the accuracy and integrity of the medical record data abstracted and encounter information prior to finalizing the encounter.
- Collaborate with the Clinical Documentation Improvement Team, Coding Team Coordinators and / or Supervisor to query for clarification of ambiguous documentation or, patient diagnostic and procedural information in the medical record.
- Be knowledgeable in the requirements of the industry with regard to Medicare and / or Managed care regulations, the International Classification of Diseases (ICD-9 and ICD-10-CM / PCS) and the Current Procedural Terminology (CPT) coding systems.
- Maintain quality and productivity standards established for the department and work under close supervision of the coding team to learn routine coding functions pertaining to low to medium complexity medical records.
The Coder 1 is responsible for performing job duties in accordance with the mission, vision, and values of Tampa General Hospital
Qualifications
Required :
Completion of the TGH Apprenticeship Program or possession of a national certification in health information management coding from the American Health Information Management Association (AHIMA), as a Certified Coding Specialist (CCS).
If not already credentialed, must obtain CCS within 1 year of hire.
- Knowledge of guidelines for the sequencing of diagnosis and procedure codes for appropriate classification systems.
- Knowledge of anatomy, physiology, pathophysiology, pharmacology and medical terminology to accurately translate medical record documentation into the appropriate classification system for reporting purposes.
- Experience in computerized encoding and abstracting software.
- Effective and professional verbal and written communication skills.
- At least one year of coding experience in an acute care setting, preferably a Trauma 1 teaching hospital or large healthcare delivery system.
- Ability to multi-task and work independently.
- Ability to efficiently complete work assignments and interact with coding leadership team to review and discuss documentation, coding and reimbursement issues.
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