Description

SUMMARY

This position accounts for the accuracy of diagnosis and procedural coding to ensure the highest level of coding is being performed while maintaining compliance with governmental and other payers for coding and billing purposes. Reports to the Manager of the Health Information Management (HIM) Department.

DUTIES/RESPONSIBILITIES (include but are not limited to the following)

• Audit, abstract and code data collected from patients medical records using ICD-10CM/PCS, CPT, and or HCPCS, in accordance with coding guidelines.
• Review narrative records of patient treatments and surgical procedures to determine what information is appropriate for coding purposes (i.e., operative reports, outpatient infusions, ER reports, etc.).
• Enter coded medical record data into applicable electronic health record system(s).
• Serves as a resource to other hospital personnel for coding items.
• Contact provider, nurse, laboratory, and other auxiliary personnel for information needed to complete, correct, or clarify medical records and/or resolve discrepancies.

Qualifications

EDUCATION AND/OR EXPERIENCE

• High School diploma or GED preferred.
• Must hold a valid coding certification through AHIMA or AAPC (RHIT, CCS, CCS-P, CPC) or applicable credential.
• Preferably 3-5 years experience with coding in a Rural Health Clinic and/or Critical Access Hospital.

SKILLS AND ABILITIES

• Working knowledge of ICD-10CM/PCS, CPT, and HCPCS coding principles.
• Ability to maintain productivity expectations.
• Able to effectively communicate professionally.
• Uses interpersonal skills effectively to build and maintain cooperative working relationships.
• Proficient software and computer skills.
• Ability to maintain confidentiality and information security in accordance to HIPAA and WCHCs policies.
• Uses a logical approach to address problems or opportunities to manage the situation at-hand using references and resources as necessary.
• Ability to work independently in an effective and consistent manner.
• Proficient in medical terminology and anatomy.