Certified Coder I

Certified Coder I

JOB SUMMARY:

Review clinical documentation and diagnostic results as appropriate to extract data and apply appropriate ICD and CPT codes for billing, internal and external reporting, research, and regulatory compliance. Under the direction of the Health Information Manager, accurately codes outpatient conditions and procedures as documented in ICD Official Guidelines for Coding and Reporting. Resolve error reports associated with billing process, identify and report error patterns, and when necessary, assist in design and implementation of workflow changes to reduce billing errors.

PRE-REQUISITES:

Education: High school diploma or equivalent required.

Experience: CCA/CPC Preferred with two years of coding or related work experience. Must be willing to obtain CCA/CPC within one year of hire. Opportunity for advancement to Coder II when years of experience criteria is met.

RELATIONSHIPS:

Reports To: Health Information Supervisor

Supervises: N/A

Other Contacts: HIM and Audit Coordinator, Leadership Team, Managers, Supervisors, Clinical Resource Nurses, all employees, Medical Staff, general public

SCOPE:

Machinery or Equipment Used: Personal computer, copier, microfilm, reader/printer, fax, laser printer, movable file units.

Physical Demands: Mostly sedentary work. Manual dexterity and mobility, occasional reaching, stooping, bending, kneeling, crouching and lifting.

Working Conditions: Office environment; occasional pressure due to multiple calls and inquiries; subject to many interruptions.

Required Protective Equipment: As the situation dictates

ESSENTIAL FUNCTIONS:

1. Assigns codes for diagnoses, treatments, and procedures according to the appropriate classification system for all assigned encounters.

2. Reviews appropriate provider documentation to determine principal diagnosis, co-morbidities and complications, secondary conditions and surgical procedures and Utilizes technical coding principals and MS-DRG reimbursement expertise to assign appropriate ICD diagnoses, procedures present on admission indicators, and all other applicable codes.

3. Extracts required information from source documentation and enters into encoder and abstracting system.

4. Assists in implementing solutions to reduce back-end billing errors.

5. Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines.