This job reviews and accurately codes and abstracts the most complex hospital services, in-patient procedures, overnight/multi-night stay services and all other complex medical services.
Utilizes appropriate coding guidelines to assign ICD and CPT codes; conforms to applicable Medicare, Medicaid and other third-party payer guidelines to ensure receipt of accurate reimbursement.
Works in collaboration with the Clinical Documentation Improvement team to ensure accurate DRG assignment and works closely with management to resolve problems and meet deadlines.
Accurately assigns ICD-10 codes within the established coding guidelines, rules and regulations.
Ensures the data integrity of coded patient records by reviewing the medical documentation and validating that documentation is sufficient to support the assigned codes.
Acts as a resource by researching patient accounts in response to questions and/or errors.
Consistently complies with established department productivity and accuracy standards.
Collaborates with the CDI nurse to identify query opportunities for documentation improvement and to ensure accurate DRG assignment.
Works in collaboration with team members and other departments to meet departmental monthly goals which may include one or more of the following: DNFB, Pre-AR, Denials and Claim Edits.
Verifies correct discharge disposition based on medical documentation.

Education Required
High School diploma or equivalent
Preferred
Completion of American Health Information Management Association (AHIMA) accredited coding program with certification.
Work Experience Required
3 years coding experience
Certifications Required
Certification as a Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), Registered Health Information Administrator (RHIA), OR a Registered Health Information Technician (RHIT)
Knowledge Skills and Abilities (KSAs) Effective verbal and written communication skills and the ability to present information clearly and professionally to varying levels of individuals throughout the patient care process.
Must have computer skills and dexterity required for data entry and retrieval of information.
Must be proficient with Windows-style applications, various software packages specific to role and keyboard.
Knowledge of ICD-9-CM, ICD-10, and coding principals.
Excellent decision making, problem solving, analytical and quality management skills. Proven ability to code complicated inpatient cases.

This employer maintains and complies with its Compliance & Privacy Program and Standards of Conduct, including the immediate reporting of any known or suspected unethical or questionable behaviors or conduct; patient/employee safety, patient privacy, and/or other compliance-related concerns.
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Senior Hospital Coder

Key skills