Responsible for reviewing and abstracting inpatient medical records
Identifying and assigning accurate medical codes for diagnosis, procedures and services
Ensures that all data elements required for federal or state reporting and billing are collected
Typically reports to the Coding Manager
Reviews medical record documentation to identify pertinent diagnosis/procedures
Queries physicians when code assignments are not straightforward or documentation in the record is inadequate
Effectively assigns ICD-10 codes and DRGs to inpatient records
Responsible in maintaining 92% to 95% in ICD-10 and DRG assignment
Ensures safe care to patients, staff and visitors
Promotes individual professional growth and development

High School Diploma or GED required
Associates degree in Health Information Management or any Healthcare Related Field preferred
Registered Health Information Technician (RHIT)
Registered Health Information Administrator (RHIA)
Certified Coding Associate (CCA)
Certified Coding Specialist (CCS)
Certified Inpatient Coder (CIC)
Five (5) years of inpatient hospital coding experience required
Strong knowledge of ICD-10-CM and PCS coding
Effective oral and written communication skills
Analytical skills necessary to interpret data contained in the health records
Strong knowledge of human anatomy, physiology, medical terminology and surgical terminology
Knowledge of coding compliance policies, official coding guidelines, regulatory requirements

Senior Certified Inpatient Coding Specialist

Key skills