DESCRIPTION OF POSITON
This job description is a record of the essential functions of the listed job. The job description provides the employee, CEO, Human Resources, applicants, and other agencies with a clear understanding of the job, where it fits into the organization, and the skill and work requirements in relation to other jobs. Jobs are always changing to some degree and the existence of the approved job description is not intended to limit normal change and growth. The facility will make reasonable accommodations to otherwise qualified individuals who are capable of performing the essential functions of the job with or without reasonable accommodation.

POPULATION SERVED
The position does not involve direct patient care for a population of patients ages 18 and older. Age specific experience and/or special training and/or expertise are not required to serve this population.

POSITION SUMMARY
The HIM Medical Coder reviews and assigns diagnosis and procedures codes to both inpatient and outpatient charts. The HIM Medical Coder works with Medical Staff and CDI to assure accurate documentation to support codes assigned. Codes are assigned using the ICD- 10-CM, CPT, DRG and/or other classification systems that may be required.

POSITION QUALIFICATIONS
The HIM Medical Coder must have a high school diploma or equivalent. Coursework: ICD-10 coding of Diagnosis, Procedures, Anatomy and Physiology at the college level. 2 years of experience required in Inpatient, Outpatient and same day and emergency room coding desired. Ability to learn EMR Systems.

LICENSES/CERTIFICATIONS:

• Certification as recognized by the American Health Information Management Association (AHIMA): CCS, CCS-P, RHIT, RHIA.
• Must have successfully completed a coding program and obtain a coding certificate within 6 months of hire.

SKILLS AND KNOWLEDGE
Must have knowledge of medical terminology. Must be able to follow written and verbal instructions, work quickly and accurately in a fast paced environment. Analytical skills are necessary to code accurately. Must have experience with computers and coding software: capable of using Microsoft Word, Excel, Outlook, computer skills for a variety of support functions. Experience with 3M Codefinder preferred.

DUTIES AND RESPONSIBILITIES

• Evaluates medical record documentation and coding to optimize reimbursement by ensuring that diagnostic and procedural codes and other documentation accurately reflect and support the visit, and to ensure that data complies with legal standards and guidelines.

• Assures codes are supported by provider documentation and initiates queries based upon other clinical documentation for accurate and reliable data collection and reimbursement.

• Identifies and corrects potential coding issues and seeks clarification of conflicting, ambiguous, or non-specific documentation prior to assigning codes.

• Adheres to use of audit worksheets for coding.

• Researches and analyzes data needs for reimbursement.

• Analyzes medical records and identifies documentation deficiencies.

• Serves as resource and subject matter expert to other coding staff.

• Reviews and verifies documentation supports diagnoses, procedures and treatment results.

• Identifies diagnostic and procedural information.

• Assigns codes for reimbursements, research and compliance with regulatory requirements utilizing guidelines.

• Identifies discrepancies, potential quality of care, and billing issues.

• Researches, analyzes, recommends, and facilitates plan of action to correct discrepancies and prevent future coding errors.

• Identifies reportable elements, complications, and other procedures.