Coding Specialist, Certified

Role Overview

• The responsibility of the Coding Specialist Certified is to search a patient's entire medical record to ensure comprehensive coding and abstracting utilizing the coding rules, principles and ethics under the supervision of the Coding Supervisor and Manager, Health Information Management.
• With quality and reimbursement contingent upon coding, it is the responsibility of the Medical Center Coding Specialist Certified to have knowledge of DRG methodology, ICD-10, CPT-4 and APC coding rules and principles.
• Reviews the medical record for diagnoses and procedures performed.
• Analyzes and searches the documentation listed in the entire medical record for all documented clinical information (diagnoses and procedures) in accordance with established procedures, daily, and trained in a minimum of 3 out of the 4 following areas: Inpatient records, Outpatient records, Emergency Room records, Clinical /Diagnostic records.
• Identifies and sequences principal diagnosis, secondary diagnoses, principal procedures, complications and comorbid conditions, for optimal reimbursement, utilizing proper coding practices, on a daily basis.
• Selects ICD 10-, CPT-4, DRG code assignments.
• Assigns proper ICD-10, CPT-4, DRG codes for all diagnoses, procedures, complications, and comorbid conditions during the course of hospitalization after researching the entire record, maintaining a 95% accuracy rate, on a daily basis.
• Performs duties involving abstracting information from the medical record and entering the information into the in-house computer systems and interfaces.

Requirements

• Graduate of an approved Health Information Management Technology program, preferred, with Registered Health Information Technician (RHIT) credentials, Certified Coding Specialist (CCS) or other relevant credential, relevant experience, required or eligible.
• As a secondary preference will also consider graduates of Medical Office Specialist program with current, acute care experience with ICD-10, CPT, DRG coding rules and methodologies with Certified Coding Specialist (CCS) or other relevant credential, relevant experience, required or eligible.
• Current, acute care experience with ICD-10, CPT, DRG, APC coding rules and methodologies preferred.
• Demonstrates knowledge of diagnostic and procedural terminology, medical terminology and disease processes (anatomy and physiology).
• Self-motivated individual with personal integrity to organize work and work independently.
• Typing skills with basic knowledge of computer operations.
• Communication skills necessary to approach the medical staff, hospital personnel, ancillary department etc. for any clarifications regarding record questions or problems utilizing coding rules and principles.

Benefits

• Health insurance
• 401(k) matching
• Flexible work hours
• Paid time off
• Professional development opportunities