POSITION SUMMARY: Reviews the entire medical record to code those conditions or diagnoses there were treated, or that affected that patient’s plan of care. Assigns ICD-10-CM codes and CPT-4, when applicable, to diagnoses, procedures and conditions to provide vital statistical data used for utilization management, quality improvement, strategic planning and reimbursement. Will assist with ED and or OBS charges by reviewing the medical record and entering associated services for coding and billing purposes.

EDUCATION, CREDENTIALS, TRAINING and EXPERIENCE:

Minimum Required: Proficient in the use of keyboard and basic computer applications. Knowledge of ICD-10-CM/CPT-4 coding procedures gained through formal training/education and/or experience. Knowledge of medical terminology and anatomy and physiology. The Incumbent should have completed or be enrolled in a Health Information Technology Program or have a broad knowledge or experience in coding.

Preferred: Certified Coding Specialist, Registered Health Information Technician, Registered Health Information Administrator

ADDITIONAL SPECIALIZED KNOWLEDGE/SKILLS: Incumbent must demonstrate an ability to apply age-appropriate principles of communication during interaction with others. Incumbent must demonstrate competence in the use of equipment and application of procedures before being allowed to perform independently.

ORGANIZATIONAL RELATIONSHIPS:

Supervises: None

Reports To: Supervisor, Coding