Coding Specialist HIM Senior

Overview

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.

• 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
• Complete other duties as assigned

Note Fully Remote Position

• 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
• Complete other duties as assigned

• 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
• Attend required hospital-wide orientations, meetings, and in-services

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.