Performs detailed analysis of documentation in patient medical records and assigns appropriate diagnostic and procedural codes for hospital reimbursement, data retrieval, and statistical analysis.
Essential functions
- Codes ICD-10-CM or CPT/HCPCS codes and creates MS-DRG, APR, and APC group assignments.
- Communicates with physicians and/or hospital departments to clarify registration and documentation issues.
- Stays current on coding guidelines and reimbursement reporting requirements and escalates concerns to the Coding Manager.
- Maintains coding credential(s).
- Follows the Standards of Ethical Coding from AHIMA and adheres to official coding guidelines and hospital/departmental policies and procedures.
- Performs other HIS-related duties as required.
Requirements & Qualifications
Qualifications
- High school diploma or GED required.
- Associate's or bachelor's degree in an AHIMA-approved Health Information Technology/Management program, or current enrollment in another related healthcare program preferred.
- 1 year of previous inpatient coding experience in a healthcare setting, preferably acute care hospital experience.
- CCS preferred; must attain CCS within 2 years of hire date.
- RHIA/RHIT credentials considered.
- Knowledge of anatomy, physiology, and medical terminology.
- Demonstrated knowledge of coding guidelines and principles.
- Ability to abstract pertinent clinical information from the medical record into 3M coding products and Meditech.
- Ability to enter coding and physician information into a computer to support compliance with ethical coding guidelines and quality data abstraction.
Location
Pennsylvania, US
Employment Type
Full-time
Experience Level
Associate
Remote work allowed
No
Posted
2 months ago