HIM Coder, CCS Required

Role Overview

• Codes and abstracts hospital medical records for diagnostic and procedural coding
• Utilizes federal, state procedures/guidelines to assure accuracy of coding and abstracting and productivity standards
• Collaborates with medical staff and clinical documentation improvement (CDI) staff to clarify documentation
• Maintains performance in accordance with corporate compliance requirements as it pertains to the coding and abstracting of medical records, as well as Diagnosis Related Group (DRG) assignment
• Accurately reviews each record and knowledgeably utilizes ICD-10-CM, ICD-10-PCS, CPT-4, and encoder to accurately code all significant diagnoses and procedures according to guidelines
• Sequences principal diagnosis and principal procedures according to documentation found in the medical records
• Utilizes ongoing knowledge and reference material regarding DRGs to validate DRG assignments
• Accurately utilizes written federal and state regulations and written guidelines regarding definitions and data elements to assure uniformity of database
• Verifies and/or abstracts required data into computer system according to procedure
• Utilizes equipment and processes appropriately, to ensure efficient coding and abstracting
• Participates in maintaining DNB and accounts receivable goal
• Maintains department level competencies
• Participates in performance improvement activities

Requirements

• Minimum of two years inpatient records coding experience or equivalent
• Ability to perform functions in a Microsoft Windows environment
• Ability to be detailed oriented and perform tasks at a high level of accuracy
• Ability to make sound decisions
• Demonstrate good communication and team work skills
• Previous experience with an electronic legal health record system preferred
• High School Diploma or GED required
• Knowledge of Anatomy & Physiology/ Medical terminology required
• Coding education preferred or equivalent in years of experience
• AHIMA Certification: Certified Coding Specialist (CCS) required for all employees hired after 10/1/2025

Benefits

• medical/prescription, dental and vision insurance
• health and dependent care flexible spending accounts
• 403(b) (401(k) subject to collective bargaining agreement)
• paid time off
• paid sick leave as provided under state and local paid sick leave laws
• short-term disability and optional long-term disability
• colleague and dependent life insurance and supplemental life and AD&D insurance
• tuition assistance
• an employee assistance program that includes free counseling sessions