POSITION SUMMARY

          Evaluates medical records, provides clinical abstracts and assigns appropriate clinical diagnosis and procedure codes in accordance with nationally recognized coding guidelines.

ESSENTIAL FUNCTIONS

• Analyzes medical information from medical records. Accurately codes diagnostic and procedural information in accordance with national coding guidelines and appropriate reimbursement requirements. Consults with medical providers to clarify missing or inadequate record information and to determine appropriate diagnostic and procedure codes. Provides thorough, timely and accurate assignments of ICD and/or CPT4 codes, MS-DRGs, APCs, POAs and reconciliation of charges.

• Abstracts clinical diagnoses, procedure codes and documents other pertinent information obtained from the medical record into the electronic medical records. Seeks out missing information and creates complete records, including items such as disease and procedure codes, point of origin code, discharge disposition, date of surgery, attending physician, consulting physicians, surgeons and anesthesiologists, and appropriate signatures/authorizations. Refers inconsistent patient treatment information/documentation to coding quality analysis, supervisor or individual department for clarification/additional information for accurate code assignment.

• Provides quality assurance for medical records. For all assigned records and/or areas assures compliance with coding rules and regulations according to regulatory agencies for state Medicaid plans, Center for Medicare Services (CMS), Office of the Inspector General (OIG) and the Health Care Financing Administration (HCFA), as well as company and applicable professional standards.

• As assigned, compiles daily and monthly reports; tabulates data from medical records for research or analysis purposes.

Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides all customers with an excellent service experience by consistently demonstrating our core and leader behaviors each and every day.

NOTE: The essential functions are intended to describe the general content of and requirements of this position and are not intended to be an exhaustive statement of duties. Specific tasks or responsibilities will be documented as outlined by the incumbent's immediate manager.

MINIMUM QUALIFICATIONS
Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Professional Coder (CPC) in an active status or Certified Coding Specialist-Physician (CCS-P) with American Health Information Management Association or American Academy of Professional Coders is preferred.

1-2 years experience coding for surgery in a hospital or ASC setting.

Must demonstrate a level of knowledge and understanding of ICD and CPT coding principles as recommended by the American Health Information Management Association coding competencies, and as normally demonstrated by certification by the American Academy of Professional Coders. Must be able to achieve an acceptable

PREFERRED QUALIFICATIONS
Additional related education and/or experience preferred.

PHYSICAL DEMANDS/ENVIRONMENT FACTORS

          OE - Typical Office Environment: (Accountant, Administrative Assistant, Consultant, Program Manager)

• Requires extensive sitting with periodic standing and walking.
• May be required to lift up to 20 pounds.
• Requires significant use of personal computer, phone and general office equipment.
• Needs adequate visual acuity, ability to grasp and handle objects.
• Needs ability to communicate effectively through reading, writing, and speaking in person or on telephone.
• May require off-site travel

SUPERVISORY RESPONSIBILITIES

None

DIRECTLY REPORTING
None

TYPE OF SUPERVISORY RESPONSIBILITIES
N/A

Leadership will strive to uphold the mission, vision, and values of the organization. They will serve as role models for staff and act in a people-centered, service excellence-focused, and results-oriented manner.

SCOPE AND COMPLEXITY

Works independently under regular supervision. Uses specialized knowledge for accurate assignment of ICD/CPT and MS-DRG codes according to national guidelines. May seek guidance for correct interpretation of coding guidelines and LCDs (Local Coverage Determinations).