Coding Specialist HIM, Senior

*** Fully Remote Position ***

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.

Essential Duties and Responsibilities

1. Code diagnostic and procedural information from the record using ICD and CPT/HCPCS classification systems
2. Utilize a computerized encoding system to facilitate accurate coding
3. Sequence diagnoses and procedures by following the ICD, Uniform Hospital Data Set, Medicare, Medicaid, and other fiscal Intermediary guidelines
4. Work cooperatively with the medical staff and other healthcare professionals in obtaining documentation to complete medical records and ensure quality coding
5. Select the DRG for each inpatient discharge and APC for each outpatient visit, ensuring coding compliance based on approved coding guidelines and conventions
6. 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
7. Enter patient information into computerized inpatient and outpatient medical record databases
8. Ensure the accuracy and integrity of medical record abstract data prior to billing interface and claims submission
9. Routinely code inpatient records to meet productivity and quality standards for inpatient coding
10. Code outpatient, emergency department, and outpatient diagnostic records as determined by Coding Operations Manager
11. Consistently maintain established productivity requirements and maintain a 96% or greater accuracy rate
12. Communicate and advise the Patient Accounts on coding and DRG/APC assignment and submission
13. Assist the Coding Compliance Specialist and/or Coding Operations Manager as needed
14. Fill-in for the Coding Compliance Specialist and/or Coding Operations Manager as needed
15. Complete other duties as assigned

Summary of Other Job Duties and Expectations

1. Adhere to the Service Excellence Standards and Expectations at Chesapeake Regional Medical Center
2. Exhibit excellent customer relations to patients, visitors, physicians, and co-workers
3. Exhibit courteous communication skills and an ability to work with others, exercising good judgment in performance of job duties
4. Demonstrate courtesy, compassion, and respect to others in adherence of the hospital's philosophy and policy for promoting  positive work and customer environments
5. Work as a team to continuously improve work quality
6. Demonstrate a commitment to flexible work schedules when it is necessary to ensure patient care
7. Present self in a positive manner as reflected by personal attire, etiquette and behavior
8. Attend required hospital-wide orientations, meetings, and in-services

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

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.