Job Description
Ability to accurately assign ICD-10-CM, CPT, ICD-10-PCS codes to applicable patient encounters
according to established guidelines. Review patients’ medical records on the nursing units, and work closely with the CDI staff to promote specificity in physician documentation.
Serves as educational / informational resource to the Medical Staff, as needed to ensure compliance with state and federal regulations.
Assist with auditing records retrospectively to validate accuracy of concurrent process and identify opportunities for improvement.
Assigns inpatient and outpatient hospital coding as well as all other assignments given by supervisors as needed.
Requirements
Associate degree in Health Information Management OR graduate of an
approved coding course OR equivalent coding experience. Five (5) years medical record coding experience. Licenses, Certifications and / or Registrations : Credentialed in Health Information Management as an RHIT, RHIA, CCS, CCA, CPC, COC, or CIC which must be obtained within three months of employment.
Specialized computer software; 3M Code finder; ICD-10-CM, ICD-10-PCS, and CPT Code Books, limited telephone, fax or copier use.
Demonstrated ability to code inpatient records and outpatient records, ability to read and write and follow oral and written instructions. Ability to form
- effective working relationship with other employees, management, and physicians. Physical Requirements : Manual dexterity and visual acuity necessary to utilize the PC and review charts;
- visual acuity also necessary for filing and proofing documents; ability to sit for prolonged periods of time; verbal communication and hearing ability to communicate with a multitude of customers;
routine lifting of approximately 15 pounds. The ability to meet the attendance requirements of the job.
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