Job Details
Description
Summary
The Senior Coding Specialist is responsible for accurately assigning and sequencing ICD diagnostic and procedural codes and/or CPT procedural codes to inpatient and outpatient records.
Essential Duties and Responsibilities
These duties and responsibilities described below represent the general tasks performed on a daily basis; other tasks may be assigned.
Code diagnostic and procedural information from the record using ICD and CPT/HCPCS classification systems
Utilize a computerized encoding system to facilitate accurate coding
Sequence diagnoses and procedures by following the ICD, Uniform Hospital Data Set, Medicare, Medicaid, and other fiscal Intermediary guidelines
Work cooperatively with the medical staff and other healthcare professionals in obtaining documentation to complete medical records and ensure quality coding
Select the DRG for each inpatient discharge and APC for each outpatient visit, ensuring coding compliance based on approved coding guidelines and conventions
Abstract medical data from the record to complete a discharge abstract on each inpatient, ambulatory surgery, emergency room, outpatient, and ancillary visit, completing and verifying diagnostic and demographic information
Enter patient information into computerized inpatient and outpatient medical record databases
Ensure the accuracy and integrity of medical record abstract data prior to billing interface and claims submission
Routinely code inpatient records to meet productivity and quality standards for inpatient coding
Code outpatient, emergency department, and outpatient diagnostic records as determined by Coding Operations Manager
Consistently maintain established productivity requirements and maintain a 96% or greater accuracy rate
Communicate and advise the Patient Accounts on coding and DRG/APC assignment and submission
Assist the Coding Compliance Specialist and/or Coding Operations Manager as needed
Fill-in for the Coding Compliance Specialist and/or Coding Operations Manager as needed
Attend required hospital-wide orientations, meetings, and in-services
Demonstrate a commitment to flexible work scheduling when necessary
Summary of Other Job Duties and Expectations
Adhere to the Service Excellence Standards and Expectations at Chesapeake Regional Medical Center
Exhibit excellent customer relations to patients, visitors, physicians, and co-workers
Exhibit courteous communication skills and an ability to work with others, exercising good judgment in performance of job duties
Demonstrate courtesy, compassion, and respect to others in adherence of the hospital's philosophy and policy for promoting positive work and customer environments
Work as a team to continuously improve work quality
Demonstrate a commitment to flexible work schedules when it is necessary to ensure patient care
Present self in a positive manner as reflected by personal attire, etiquette, and behavior
Supervisory Responsibilities
Reports to:
HIM Coding Operations Manager
Supervises:
N/A
Responsibilities:
N/A
Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education and Experience
Minimum Required Education:
Completion of a Health Information Management program with AHIMA approval status or coding program with AAPC
Preferred Education:
N/A
Experience:
4+ years recent experience coding in an acute hospital setting required; coding ability will need to be demonstrated via a skills assessment
Certificates, Licenses, Registrations
Certification in RHIA or RHIT and CCS or CIC is required. In addition, also prefer outpatient coding certifications through AHIMA and AAPC.
Qualifications
Education
Preferred
Associates or better in Health Information Management or related field.
Experience
Required
4 years:
experience coding in an acute hospital setting required
Licenses & Certifications
Required
Registered Health Info Ad
Equal Opportunity Employer
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