Job Description

General Summary of Position
Codes and abstracts primarily Inpatient records using ICD-10-CM and other applicable patient classification schemes.

M inimum Qualifications
Education

• High School Diploma or GED equivalent required
• Associate's degree in coding or Bachelor's degree in coding related degree preferred
• Courses in Medical Terminology, Anatomy & Physiology, ICD-CM and ICD-PCS required

Experience

• Experience with clinical information systems (3M grouper, electronic medical records, computer assisted coding) and coding experience

Licenses and Certifications

• CCS (Certified Coding Specialist) required within 1 year from date of hire. within 1 Year Required and
• RHIT (Registered Health Information Technician) Preferred and
• RHIA (Registered Health Information Administrator) Preferred

Knowledge, Skills, and Abilities

• Verbal and written communication skills.
• Basic computer skills required.

Primary Duties and Responsibilities

• Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.
• Abstracts and ensures accuracy of diagnoses, procedure, patient demographics, and other required data elements.
• Adhere to all compliance regulations and maintains annual compliance education.
• Maintains continuing education and seeks ongoing education to improve job performance. Maintains credentials as required for job classification.
• Contacts physician when conflicting or ambiguous information appears in the medical record. Adheres to the MedStar Coding Query Policy and procedure.
• Meets established Quality standards as defined by policies.
• Meets established Productivity standards as defined by policies.
• Resolves all quality reviews timely (e.g. Medical necessity reviews; Coding Quality assurance reviews; external vendor reviews).
• Reviews medical record documentation to identify diagnoses and procedures. Assigns correct diagnostic and procedural codes using standard guidelines and automated encoding software maintaining departmental accuracy standards. Determines the sequence of diagnoses according to Uniform Hospital Discharge Data Definitions and assigns appropriate DRG (Diagnosis Related Groups).
• Exhibits knowledge of the 3M system and other work-related equipment.
• Participates in meetings and on committees and represents the department and hospital in community outreach efforts.
• Participates in multi-disciplinary quality and service improvement teams.
• Performs other duties as assigned.

This position has a hiring range of $28.20 - $44.83

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