Facility Cape Fear Valley Medical Center Location Fayetteville, North Carolina Department Health Information Management Job Family Clerical Work Shift Variable (United States of America) Summary Reviews thoroughly the entire medical record to code specifically and accurately those conditions or diagnoses that were treated or affected the patient's plan of care. Verifies that each medical record contains appropriate documentation to justify the selected principal diagnosis to identify comorbid conditions, complications and procedures to use for DRG Assignment. Maintains an accurate case mix index from which administration makes critical management and strategic planning decisions.5 years coding experience required, preferably in a hospital setting. Two years inpatient coding preferred. Experience in a Health Information Management in an acute care facility, or with a Peer Review Organization, in Quality Assurance, or Utilization Review preferred. Bachelor's Degree in Health Information Management or equivalent training and experience. RHIA, RHIT, CCS or other equivalent credentials required. Medical terminology, anatomy and physiology, familiarity with medical record content and an understanding of the Uniform Hospital Discharge Data Set (UHDDS) definitions. Knowledge of ICD-CM coding principles under Prospective Payment System. Excellent communication skills required. Highly independent in that decisions are made with very serious impact affecting hospital reimbursement and PRO review determinations. High degree of interpretation, analysis, planning, coordination, and organization of information. Decisions require intense mental effort and consideration of reimbursement ramifications. Utilizes past experience, practices and organization to accomplish goals. Assigns accurate codes using good judgment in a timely manner within broad guidelines. Must be flexible and able to concentrate in a busy, noisy, and crowded environment with demands and interruptions 75% of the time.Near visual acuity required. Motor coordination required to operate computer. Work requires commuting between nursing units and Medical Record Department. Required Licenses and Certifications RHIA - American Health Information Management Association Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity For exceptional healthcare come to Cape Fear Valley Health where caring employees are committed to integrity, patient-centeredness and excellence throughout the entire healthcare process. At Cape Fear Valley Health, our goal is to improve the quality of every life we touch. Our diverse team of doctors, nurses and staff work together to create a better experience for every patient, every time. Cape Fear Valley is a 950-bed, 8-hospital regional health system, the 8th largest in North Carolina, with more than 1 million inpatient and outpatients annually. A private not-for-profit organization with over 7,000 employees and 850 physicians. Our employees and physicians proudly serve a seven-county region of southeastern North Carolina, including Fayetteville, Fort Bragg, Hope Mills, Raeford, Lumberton, Elizabethtown, Clinton, Lillington, Dunn and beyond. Our medical facilities include Cape Fear Valley Medical Center, Highsmith-Rainey Specialty Hospital, Cape Fear Valley Rehabilitation Center, Behavioral Health Care, Bladen County Hospital, Hoke Hospital, Central Harnett Hospital, Betsy Johnson Hospital, as well as more than 60 medical offices and specialty care clinics spread throughout the Cape Fear region.