Job Purpose & Position Overview

The purpose of this position is to maintain accurate and timely completion of medical record coding. Being able to work independently and efficiently in a fast-paced environment is a must. This position requires extensive attention to detail, multi-tasking, and strong communication skills with our healthcare providers. Effective and independent problem solving is the key to success in this role.

Specific Job Duties/Responsibilities:

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  Ensure accurate completion of coding for medical records
• Assigns codes to diagnoses and procedures for medical records using current ICD-10 CM and CPT Professional coding classification systems
• Analyze medical record for completeness and quality of documentation with direct communication to clinical staff for clarification of conflicting documentation
• Meet productivity and quality standards
• Requires ongoing review and adherence to a multitude of regulatory requirements that are constantly changing
• Applies professional knowledge and uses critical thinking skills to assign codes to meet various payment groupings and medical necessity
• Ability to provide education to physicians, clinical staff and other healthcare professionals regarding changes to coding guidelines and policies
• Works extensively with electronic medical record
• Proficient or the ability to become proficient in utilizing coding software
• Maintains HIPAA standards
• Upholds the hospital’s vision, mission and values

Other Job Duties:

• In addition to daily coding requirements, this employee may also be required to assist with other health information management duties such as release of information, electronic medical record workflows, answering phones, customer service, etc.

Required Qualifications/Skills:

• Professional Coding Certification from AHIMA or AAPC required
• Ability to obtain professional coding certification within 12 months of employment

• Specialized knowledge of ICD-10, CPT and HCPCS Coding Procedures; Medicare & Medicaid Policies & Regulations
• Extensive knowledge of E/M guidelines preferred
• Analyze medical records for complete documentation and directly communicate with providers to receive clarification on any documentation that is incomplete or inaccurate
• Work directly with the physicians to correct any documentation deficiencies
• Educate physicians, clinical staff, and other healthcare staff on changes to coding policies, standards and regulations and promote proper documentation practices
• Skill in a variety of software systems; including electronic medical record software, Word, Excel, and Outlook
• Work requires extreme attention to detail and work which meets high ethical standards and logical thinking
• Extensive knowledge of anatomy, physiology, disease processes and medical terminology
• Work extensively with protected health information and is required to adhere to HIPAA privacy and security regulations and policies
• Ability to communicate in a professional manner; both verbally and in writing
• Ability to work independently and collaboratively as part of a team with multiple priorities and deadlines
• Must comply with a coding accuracy rate of 95% as per coding policy

Physical Requirements:

This role operates in a healthcare setting. This position requires frequent sitting and computer work and allows employee to vary physical position or activity for comfort.

• Normal to light office work which includes the ability to lift up to 10 lbs.

• Regularly required to walk, stand, and sit for extended periods of time and use hands to operate computer keyboard, phone, and various office equipment.

Cognitive Requirements:

• Reading, writing, calculating.
• Excellent social interaction skills

• Reasoning/Analysis
• Ability to work effectively both independently and as a team
• Works with minimal supervision

Language Requirements:

• Must possess the ability to read, write, and speak the English language fluently.
• Must be able to continually and effectively employ professional verbal and written communications skills.

Certificates, Licenses & Registrations:

• 
  High School Graduate or equivalent
• Coding certification or willingness to obtain certification within 12 months of hire
• All applicants will comply with 45 CFR 1301, Subpart D, Section 1301.31, C and D, which require all prospective employees to sign a declaration prior to employment regarding all arrests and convictions of child abuse or violent felonies and to comply with PL 101-630 and PL 101-637 regarding criminal records check.