Job Requirements
Position Summary
To be fully engaged in providing timely, complete, and accurate data collection for quality clinical analysis and revenue enhancement.
PRIMARY ACCOUNTABILITES
1. Uphold regulatory compliance by assigning and sequencing accurate ICD 10 and CPT 4 codes
to reference lab, ancillary, emergency room, endoscopy, ambulatory surgery, observation, and
other outpatient records as per coding guidelines demonstrating behavior that reflects integrity,
shows a commitment to ethical and legal coding practices, and fosters trust in professional
activities.
2. Validate accuracy of codes assigned by the computer assisted coding software, recognizing
inappropriate application of clinical coding rules/guidelines, and revising the codes assigned
based upon expert subject matter knowledge and provider documentation.
3. Literacy and proficiency in computer technology specifically related to health information and
coding applications utilized for daily job performance.
4. Interpret clinical documentation to ensure codes reported are clearly and consistently supported
by the health record.
5. Request clarification from provider when there is conflicting, incomplete, or ambiguous
information in the health record regarding a significant reportable condition or procedure or
other reportable data element.
6. Abstract pertinent information accurately and completely into the computer assisted coding
application.
7. Maintain coding quality and productivity as per departmental standards.
8. Competent in analyzing medical necessity of codes assigned utilizing and applying local and
national coverage determination regulations and guidelines.
9. Responds timely to pre-bill edits received ensuring a prompt turn-around-time to assist in
facilitating an efficient revenue cycle.
10. Communicates professionally identified discrepancies, documentation issues, denial
management issues and coding concerns in the medical record to the appropriate department
and/or leader.
11. Stays up to date with regulatory changes by completing all mandatory educational
accountabilities in a timely manner.
12. Attends department meetings and other outpatient meetings as scheduled.
13. Accurate and ethical time and attendance recording ensuring non-productivity logs are
completed and submitted by deadline set.
14. Provide departmental coding coverage by cooperating with occasional schedule revisions and
overtime requests when staffing needs arise assisting with maintenance of discharge not final
coded (DNFC) departmental goals.
15. Maintain and observe patient confidentiality as outlined in the National Patient Safety Goals and
HIPAA guidelines always protecting the confidentiality of the health record and refusing to
access protected health information not required for coding-related activities
Work Experience
MINIMUM QUALIFICATIONS
o Competent in understanding medical terminology.
o Basic understanding of anatomy and physiology.
o Excellent communication, problem solving and critical thinking skills.
o Utilize critical thinking skills and formulate logical decisions to apply clinical coding
guidelines to health record documentation.
o Strong written and oral communication skills for professional interaction.
o Excellent computer and telephone skills.
o Ability to read and comprehend instructions, correspondence, memos, and electronic
mail.
o Must be detail and accuracy oriented.
o Ability to coordinate and use logical reasoning to facilitate daily workflow assignments.
o Ability to multi-task.
o Ability to work independently maintaining focus on scope of work assigned.
PREFFERED QUALIFICATIONS
o American Health Information Management Association (AHIMA) OR
o American Academy of Professional Coders (AAPC).
PHYSICAL REQUIREMENTS
to moderate noise.
personal vehicle.
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