Requirements :
Current registration for : RHIA, RHIT, CCS or CCA Licenses
Minimum of five years inpatient coding / abstracting experience.
Other Duties :
Reviews the entire medical record to determine the diagnoses and procedures that occurred during the encounter and calculate a DRG for the purpose of hospital reimbursement
Assess the documentation to determine if it is sufficient to support the diagnoses and procedures.
Proficiently engages the 3M Encoder through Paragon system to ensure proper coding and sequencing.
Selects and sequences the appropriate ICD-10-CM and / or CPT codes to reflect the correct principal and secondary diagnoses and procedures and the optimal payment allowed.
Consults with physicians and / or director for clarification when there is conflicting or ambiguous documentation in the chart.
Ensures DNFB accounts are coded on a routine basis.
Consults with physicians and / or director for clarification when there is conflicting or ambiguous documentation in the chart.
Maintains expected accuracy standards set by the department director.
Adheres to established organizational / departmental policies and procedures.
Participates in peer review and other coding and abstracting quality monitors.
Position Qualifications :
Data entry knowledge.
Computer knowledge.
Understands and adheres to the Medical Center’s Code of Conduct.
Familiar with the Medical Center’s Mission, Vision, and Values Statements.
Education :
Health Information Management Associates or related
Job Setting / Physical Demands :
Office Setting / Remote (Hybrid)
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