• Assess the adequacy of medical record documentation to ensure it supports all reportable diagnoses and procedures. 
• Assigns proper ICD and CPT diagnosis and procedure codes in accordance with official coding guidelines.
• Contact the physician and/or staff when necessary to gain additional information or clarify documentation discrepancies.
• Communicate daily to appropriate persons regarding any issues or concerns pertaining to coding, abstracting or billing. 
• Perform edit checks on data entered prior to transmittal and corrects errors as indicated.
• Works closely with key Revenue Cycle Management (including, but not limited to, Billing, Claims Follow-up, Appeals) teams for resolution of charge issues in a timely manner.
• Conducts daily charge and documentation reconciliation to ensure all charges are captured and supported. 
• Examine all documents in the record for authorized signature and patient identification to ensure all documents contain sufficient documentation to support the diagnosis and treatment administered, and the results obtained are adequately described.
• Maintain an up-to-date knowledge and understanding of current trends and widely accepted practices related to Health Information Management
• Pursue professional growth and development opportunities. 

• Medical Record Documentation Assessment (Hard Skills)
• ICD and CPT Coding Compliance (Hard Skills)
• Physician and Staff Communication (Soft Skills)
• Issue Resolution and Communication (Soft Skills)
• Data Edit Checks and Error Correction (Hard Skills)
• Revenue Cycle Management Collaboration (Soft Skills)
• Charge and Documentation Reconciliation (Hard Skills)
• Health Information Management Knowledge and Development (Hard Skills)

Job Summary:

• Assign and sequence ICD-10-CM, ICD-10-PCS and CPT codes for all specialty patient types which may include outpatient, ambulatory surgery, emergency room records, obstetrical and neonatal records and inpatient records.
• Accurately code outpatient ambulatory records
• Accurately code outpatient referred cases and ancillary visits
• Accurately code and abstract Emergency Department records
• Accurately code Obstetrical and Neonatal records
• Accurately code Inpatient records
• Maintain coding accuracy performance above 95 percent by appropriately assigning ICD-10-CM and CPT codes according to guidelines.
• Abstract clinical data, including discharge disposition, accurately after documentation assessment.
• Query physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes
• Select and assign revenue codes based on CPT codes, where appropriate.
• Perform medical record review for the timeliness and completeness of clinical documentation.
• Participate in continuing education activities to enhance knowledge, skills and keep credentials current.

Skills on Resume: 

• ICD-10-CM and CPT Coding Proficiency (Hard Skills)
• Accuracy in Coding (Hard Skills)
• Abstracting Clinical Data (Hard Skills)
• Physician Querying (Hard Skills)
• Revenue Code Selection (Hard Skills)
• Medical Record Review (Hard Skills)
• Continuous Learning (Soft Skills)
• Attention to Detail (Soft Skills)

Job Summary:

• Codes all outpatient records, utilizing ICD-10, CPT, and HCPCS according to coding guidelines, plus Rural Health Regulations.
• Maintains current knowledge on revisions and modifications to CPT-4 and ICD-10-CM codes.
• Interprets provider service documentation and queries the medical staff for clarification of coding issues.
• Utilizes local medical review policies for compliance issues
• Utilizes appropriate resource materials, including intranet and internet, for proper billing for outpatient and physician service.
• Stays updated on new and revised regulations.
• Performs chart/charges review for submission of accurate and complete claims.
• Assists financial associates/billers with interpretation to expedite billing and answers to patient questions.
• Maintains a 24-hour turnaround from receipt of documentation and encounter form.
• Perform report running for mental health notification.

Skills on Resume: 

• Expertise in Medical Coding Systems (Hard Skills)
• Regulatory Knowledge (Hard Skills)
• Interpretation and Querying Skills (Soft Skills)
• Compliance and Policy Utilization (Hard Skills)
• Resource Utilization (Hard Skills)
• Chart and Charges Review (Hard Skills)
• Communication and Assistance (Soft Skills)
• Time Management (Soft Skills)

Job Summary:

• Responsible for coding for hospital outpatient units & clinics such as COVID Lab cases, Same-Day Surgery, Observation and Oncology
• Gather information to determine reimbursement levels, assess the quality of patient care and study any identifiable patterns of illnesses
• Code and abstract clinical and demographic data for inpatient, outpatient, and clinics
• Use ICD 10 and CPT coding, following rules and regulations
• Performs diagnostic and procedural coding by utilizing the 3M encoder with the use of books only as a reference.
• Reviews and analyzes entire content of current medical record of discharged patients to identify final principle diagnosis and any applicable secondary diagnoses, along with the principle procedure and any secondary procedures performed according to Department and Coding Guidelines.
• Assigns appropriate codes for Inpatient and Rehabilitation Services using the International Classification of Disease system (ICDNj-CM, ICDᆞ-CM/PCS) and Current Procedural Terminology (CPTdž).
• Verifies demographic information downloaded from the Epic system into the 3M Coding and Reimbursement system.
• Identifies and reports significant deficiencies in information and assure that the appropriate diagnosis procedures are used to obtain the correct and proper reimbursement.

Skills on Resume: 

• ICD-10 and CPT Coding Proficiency (Hard Skills)
• Medical Record Review and Analysis (Hard Skills)
• Encoder Software Utilization (Hard Skills)
• Data Abstraction and Coding (Hard Skills)
• Reimbursement Assessment (Hard Skills)
• Regulatory Compliance (Hard Skills)
• System Integration and Verification (Hard Skills)
• Deficiency Identification and Reporting (Hard Skills)

Job Summary:

• Ensure patient record documentation meets state and federal regulations for content, completeness, and timeliness.
• Code ED, Outpatient, and Inpatient accounts correctly to ensure coding guideline are followed for appropriate reimbursement, utilizing Alpha II coder, Code Correct, and AMA ICS-10-CM, and HCPCS coding books.
• Accurately completes chart review to ensure accuracy and completeness for analytical, statistical, and patient care purposes.
• Call physicians and ancillary departments to get correct diagnosis to complete coding procedures.
• Physically locate and wait for physicians, nursing staff, and therapists to obtain correct diagnosis to complete coding procedures.
• Assures timely completion of chart deficiencies by promptly recording such deficiencies in the ICR desktop and by providing healthcare staff with the information they require to complete the deficiencies.
• Receiving calls from ancillary departments, physician offices, etc to get correct ICD-10 and CPT coding.
• Transcribe “STAT” dictations as a priority and other transcription
• Refer inconsistent or incorrect coding by provider to management when a trend or pattern is identified.
• Respond and process all requests for copies of medical records from other healthcare facilities, over the phone, and walk-in requests, ensuring correct requests are filled out properly.
• Responsible for establishing and maintaining healthy interpersonal relationships with all staff members.
• Recognize the important part this position plays in Performance Improvement of the ongoing delivery of patient care.
• Reacts properly and follows correct policy and procedure in an emergency and/or disaster.
• Wear Personal Protective Equipment (PPE) as situations require maintaining Infection Control standards set by hospital.

Skills on Resume: 

• Regulatory Compliance (Hard Skills)
• Medical Coding Expertise (Hard Skills)
• Chart Review Accuracy (Hard Skills)
• Effective Communication (Soft Skills)
• Deficiency Management (Hard Skills)
• Transcription Proficiency (Hard Skills)
• Problem Identification and Reporting (Hard Skills)
• Customer Service and Interpersonal Skills (Soft Skills)

Job Summary:

• Assures that proper documentation is available in the medical record prior to coding, and that it is complete,
• Demonstrates knowledge and remains current in regard to ICD-10, CPT codes and modifiers.
• Identifies additional charges for implants and devices, applying appropriate HCPCS codes,
• Provides feedback and training to the clinical staff on coding issues and reviewing denials,
• Maintains required certification and training in the areas of coding and abstracting,
• Remains current with workload, coding ad processing records in a timely manner,
• Demonstrates expertise in the use of automated coding systems,
• Interacts positively in a friendly and professional manner with physicians, patients/family, office staff, hospital staff, medical supply company representatives, insurance companies, and others,
• Accountable for conversion of diagnoses and procedures into codes using international classification of diseases (ICD-10) and current procedural terminology (CPT).
• Requires skill in the sequencing of diagnoses and procedures to optimize reimbursement.
• Ensures that records are coded in an accurate and timely manner.

Skills on Resume: 

• Proficiency in ICD-10 and CPT Coding (Hard Skills)
• Accuracy in Documentation and Coding (Hard Skills)
• Expertise in HCPCS Codes (Hard Skills)
• Training and Feedback Abilities (Soft Skills)
• Certification and Continuing Education (Hard Skills)
• Timeliness and Efficiency (Soft Skills)
• Automated Coding System Proficiency (Hard Skills)
• Professional Communication and Interaction (Soft Skills)

Job Summary:

• Code outpatient, and ancillary records using ICD-10-CM and CPT-4 coding guidelines for correct APC/APG assignment. 
• Assign the Physician's Evaluation/Management service code. 
• Perform clinical and demographic abstracting in UDS and Meditech computer system. 
• Enter deficiencies in the chart tracking system. 
• Review charts for data retrieval for hospital/medical staff quality, risk and infection control activities.
• Demonstrates the ability to appropriately use ICD.10 and CPT coding principles to code to the highest level of specificity that complies with CMS regulations and company goals and policies.
• Understanding of various third party billing requirements, while preparing paper and electronic claims for timely submissions to insurance carriers with the ability to work independently.
• Identifies and reports issues or errors, such as incomplete or missing records and documentation, ambiguous or non-specific documentation, or codes that do not conform to approve coding guidelines, while utilizing professional communication skills.
• Demonstrate the ability to self-report daily tasks and assignments as well as identify any billing trends that affected daily billing productivity.
• Assists A/R collectors with resolving coding conflicts with third-party carriers. 
• Investigate and resolve EDI rejections. 
• Daily batches and reports.

Skills on Resume: 

• ICD-10-CM and CPT-4 Coding Proficiency (Hard Skills)
• Clinical and Demographic Abstracting (Hard Skills)
• Chart Tracking and Deficiency Management (Hard Skills)
• Data Review and Quality Assurance (Hard Skills)
• Billing and Claims Preparation (Hard Skills)
• Issue Identification and Resolution (Hard Skills)
• Self-reporting and Billing Trend Analysis (Hard Skills)
• Support for A/R Collectors and EDI Rejections (Hard Skills)

Job Summary:

• Review analyze and approve codes for diagnostic and procedural information that determines Medicare, Medi-Cal and private insurance payments.
• Perform ICD-10-CM, CPT and HCPCS coding for reimbursement.
• Ensure compliance with established coding guidelines, third-party reimbursement policies, regulations and accreditation guidelines.
• Review ICD-10-CM, CPT and HCPCS codes against documented information for Dignity Health Medical Foundation clinical encounters.
• Assure the final diagnoses and operative procedures as stated by the physician are valid and complete.
• Review necessary information from health records to identify proper and congruent relationships between procedure 
• Diagnosis codes utilizing EndCoder systems, LCD's, NCD's and modifier relationships.
• Determine the final diagnoses and procedures stated by the physician or other health care providers are valid and complete.
• Open lines of communication with the health care professional 
• Resolve discrepancies in coding practices and provide education
• Perform a comprehensive review for the record to assure the presence of all parts 
• Patient and record identification, signatures and dates where required, and other necessary data in the presence of all reports that appear to be indicated by the nature of the treatment rendered.
• Analyze provider documentation to assure the appropriate Evaluation & Management (E & M) levels are assigned using the correct CPT code using both 1995 and 1997 CMS guidelines for auditing.

Skills on Resume: 

• ICD-10-CM, CPT, and HCPCS Coding Proficiency (Hard Skills)
• Regulatory Compliance and Guidelines Adherence (Hard Skills)
• Detailed Review and Validation (Hard Skills)
• EndCoder Systems and Modifier Relationships (Hard Skills)
• Communication and Collaboration (Soft Skills)
• Analytical Skills for Documentation Review (Hard Skills)
• Attention to Detail (Hard Skills)
• Educational and Discrepancy Resolution Abilities (Soft Skills)

Job Summary:

• Prepare all inpatient and outpatient insurance and patient claims that need to be billed according to the proper method requested by each company for primary and secondary insurance promptly.
• Maintain productivity in line with department standards
• prepare secondary insurance billing accounts.
• Ensure the correctness of all information when filing insurance claims
• Provide quality feedback as it relates to the quality, accuracy, and timeliness of other departments as it relates to the billing process.
• Keep accurate records of all patients, under the scope of responsibility, which includes keeping accurate information on account activity as well as providing appropriate file documentation to include accurate assignment of payer class to maintain accurate records
• Be familiar with regulatory charges issued by intermediaries and insurance companies to determine how charges could impact claims processing and communicate with managers about such changes.
• Demonstrate a thorough knowledge and understanding of billing policies and procedures in performing job duties and instructing patients and hospital personnel
• Routinely using the Revenue Cycle Guidelines and other reference materials as necessary to ensure the proper course of action in billing, follow-up, and collections.
• Provide feedback to the Office Manager as to the accuracy of coding as it impacts billing and reimbursement.
• Report the status of all accounts under the scope of responsibility including the timely response to all requests and inquiries by the Office Manager.
• Process correct claims, i.e. late charges, utilize the CPT, ICD10 manuals and continue to grow in the use of the computer system as its capabilities expand.

Skills on Resume: 

• Insurance Billing and Claims Processing (Hard Skills)
• Regulatory Knowledge (Hard Skills)
• Attention to Detail (Soft Skills)
• Productivity Management (Soft Skills)
• Knowledge of Billing Policies and Procedures (Hard Skills)
• Communication Skills (Soft Skills)
• Technical Proficiency (Hard Skills)
• Quality Assurance (Soft Skills)