JOB SUMMARY

Accountable for conversion of diagnoses and treatment procedures into codes using an international classification of diseases.

Requires skill in the sequencing of diagnoses / procedures to optimize reimbursement. Ensures that patient records are coded in an accurate and timely manner.

Reports to HIM Director. Non-Exempt position.

ESSENTIAL FUNCTIONS

• Ensures that records are coded within the current UMH deadline (i.e. 4 days of discharge, excluding weekends and holidays).
• Reviews chart thoroughly to ascertain all diagnoses / procedures.
• Contacts responsible physician in a professional, tactful manner, if diagnosis is not available on chart.
• Ensures coded diagnosis and procedures on clinical summary agree with physician.
• Refers chart to director, if there is a question regarding the diagnoses / codes.
• Utilizes computerized coding / abstracting equipment.
• Codes all diagnoses / procedures in accordance to ICD-10-CM and CPT-4 coding principles and the Coding Manual.
• Meets quality standards of having 95% of principal diagnoses and procedures appropriately and / or correctly coded.
• Reviews coding periodicals within 7 days of receipt.
• Notifies director whenever work is more than 48 hours behind work deadline.
• Assists the director with state requirements and reports.
• Ensures data quality and optimum reimbursement allowable under the federal and state payment systems.
• Acts as a resource person to hospital staff for coding and may provide education regarding coding changes / issues.
• Must be familiar with all charting and coding requirements, coding guidelines and coding clinics.
• Performs concurrent coding for Clinical Documentation Improvement (CDI) (for inpatient coder only)
• Review query logs.
• Work up and enter CRNA charges.
• Willing to accept additional assignments.

POSITION REQUIREMENTS

Minimum Education

High School graduate or equivalent required.

Coding certification required within one year of employment, to include Certified Coder Specialist (CCS), Registered Health Information Administrator (RHIA), Registered Health Information Technologist (RHIT), or Certified Outpatient Coder (COC) designation preferred.

Two or more years of previous hospital experience in inpatient and / or Outpatient coding preferred.

Required Skills

Must possess superior ability to communicate effectively in English, both verbally and in writing. Additional languages preferred.

Must possess high degree of organization and be able to multi-task efficiently and effectively.

Advanced computer knowledge required, including proficiency in Microsoft Office and Outlook.

Ability to use standard office equipment (copier, fax, etc.).

FUNCTIONAL DEMANDS

Functional Job Requirements :

Job requirements include, but are not limited to : sitting, standing, walking, kneeling, bending, squatting and reaching.

Requires good finger dexterity, repetitive motions with hands and fingers. Requires ability to have good vision and hearing.

Pushing and pulling equipment may be necessary.

Lifting Requirements

Job requires light lifting on an occasional basis.

Reasonable Accommodations

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising the job duties.

Last updated : 2024-04-28