Certified Coder

Overview

Using established policies and procedures; the Certified Coder translates narrative descriptions of diseases, injuries, and medical procedures into numeric or alphanumeric codes needed for billing. The Certified Coder may code all types of inpatient, observation and outpatient cases (to include clinics, ancillary services, and ambulatory surgery, series, and emergency room cases) and may be called upon to code highly complex inpatient records (to include trauma, burns, open heart and transplant cases) based on experience and skill set.

High school graduate required.
Associate Degree preferred |
Registered Health Information Technician (RHIT) preferred, (or RHIT eligible) | 2 years experience in Health Information Management or related health care/office experience
.

• Coding quality - 40% - Reviews inpatients, ambulatory, observation, emergency and outpatient accounts to assign accurate ICD-10 and/or CPT codes and DRGs. Interprets health record content to ensure that all diagnoses and procedures coded are supported by physician documentation. Maintains a coding accuracy rating of at least 95% on records assigned. Queries physicians when necessary to ensure documentation supports the codes assigned.
• Coding productivity - 40% - Performs coding on medical records in an efficient manner meeting productivity standards and assisting the department in meeting and maintaining its goals. Completes productivity data correctly and timely.
• Billing edits, coding corrections, DRG changes - 10% - Reviews, researches, and resolves claim edits for billing purposes. Reviews records following feedback from payers, auditors and managers and makes corrections to coding, disposition and/or DRG assignment when indicated.
• Accountability - 10% - Reviews educational materials thoroughly and takes responsibility for applying this information when coding. Seeks to clarify information and educational material when necessary. Listens actively. Maintains information and resources in an organized manner so that information can be referenced easily. Reviews emails timely and thoroughly and responds when indicated. Manages the remote work setting effectively and comes on site when system, connectivity or other issues arise that would impact work performance.

• Climbing:
  Ascending or descending stairs, ladders, ramps, etc, using feet and legs and /or hands and arms - 5%
• Stooping:
  Bending body downward and forward by bending spine at the waist - 5%
• Kneeling:
  Bending legs at knees to come to a rest on knee or knees - 5%
• Reaching:
  Extending hand(s) and arm(s) in any direction - 5%
• Standing:
  Remaining upright on the feet, particularly for sustained periods of time - 5%
• Walking:
  Moving about on foot to accomplish tasks - 5%
• Pushing 0-10 lbs:
  Use of upper extremities to press against something with steady force in order to move something forward, downward or outward - 5%
• Pushing 11-20 lbs:
  Use of upper extremities to press against something with steady force in order to move something forward, downward or outward - 5%
• Pushing 21-50 lbs:
  Use of upper extremities to press against something with steady force in order to move something forward, downward or outward - 5%
• Pushing 51 lbs or more:
  Use of upper extremities to press against something with steady force in order to move something forward, downward or outward - 5%
• Pulling:
  Use of upper extremities to exert force in order to drag, haul or tug objects in a sustained motion - 5%
• Lifting 0-10 lbs:
  Raising objects from a lower to a higher position, or moving objects horizontally from position-to-position and requires the use of upper extremities and back muscles - 5%
• Lifting 11-20 lbs:
  Raising objects from a lower to a higher position, or moving objects horizontally from position-to-position and requires the use of upper extremities and back muscles - 5%
• Lifting 21-50 lbs:
  Raising objects from a lower to a higher position, or moving objects horizontally from position-to-position and requires the use of upper extremities and back muscles - 5%
• Lifting 51 lbs or more:
  Raising objects from a lower to a higher position, or moving objects horizontally from…