• Complies with established departmental policies and procedures, objectives, safety, environmental and infection control standards
• Utilizes and demonstrates skills/knowledge to communicate with and deliver assistance to adult, geriatric and pediatric patients
• Orients, instructs and trains assigned personnel and volunteers
• Cooperates with other personnel to achieve department objectives and maintain good employee relations, interdepartmental objectives, and infection control policies
• Consistently demonstrates a professional and proactive attitude and actions in all interfaces with employees, hospital staff and physicians as well as patients
• Provides for privacy and patient/employee dignity by maintaining employee/patient and departmental confidentiality with no infractions
• Promotes personalized care and attention by complying with appropriate hospital/departmental dress code, wearing nametags and introducing themselves to employees, patients and others
• Answers phone and responds to verbal requests promptly
• Phones with in three rings and response to verbal requests within 30 minutes
• Codes and abstracts all medical records for reimbursement and research

Skills: Policy Compliance, Patient Communication, Staff Training, Team Cooperation, Professional Attitude, Confidentiality Maintenance, Personalized Care, Medical Coding

• Coding complies with federal regulations according to diagnoses, operations and procedures using ICD-9-CM and CPT codes
• Accurately codes ED and OP registrations, maintaining a 95% accuracy rate
• Daily assures that all codes are entered into the AS400 System and runs SMART daily
• Reviews monitoring reports to ensure that no outstanding accounts are awaiting final diagnosis
• Serves as a liaison between medical records and the business offices of the hospital and the physician offices regarding any coding questions or discrepancies
• Assists in training in coding
• Responsible for continuing education and completion of lessons
• Responsible for the maintenance of timely coding
• Responsible for clerical functions in the absence of clerical support
• Understands HIPAA, privacy and confidentiality 

Skills: ICD Coding, CPT Coding, Data Accuracy, Report Review, Liaison Support, Coding Training, Timely Coding, HIPAA Compliance

• Assures that all principal and secondary diagnoses are abstracted from the patient record
• Codes in accordance with accepted guidelines, maintaining
• Assures that all CPT procedures are abstracted from the patient records
• Verifies the correct Diagnostic-Related Group (DRG) code for billing is assigned and “right coding” is obtained
• Refers appropriate questions regarding final diagnoses/operative procedures to the responsible physician by completing a query form
• Follows departmental physician query procedures
• Holds accounts to maintain control and a follow-up mechanism
• Completes the coding of accounts in HDM and Epic
• Assures all returned accounts are handled timely, accurately, and completely
• Complete daily productivity report
• Responsible for assigning codes to diagnoses and procedures, using ICD (International Classification of Diseases) and CPT (Current Procedural Terminology) codes
• Ensures codes are accurate and sequenced correctly in accordance with government and insurance regulations
• Communicates with other clinical staff regarding documentation
• Searches for information in cases where the coding is complex or unusual
• Receives and reviews patient charts and documents for accuracy
• Ensures that all codes are current and active

Skills: Diagnosis Abstraction, CPT Procedures, DRG Verification, Physician Query, Account Management, Epic Coding, Productivity Reporting, Code Accuracy

• Assign ICD-10-CM Diagnosis Codes and ICD-10-PCS Procedure Codes for assigned accounts
• Select and sequence principal and secondary diagnosis and procedure codes
• Assign appropriate DRG
• Review the medical record and all applicable documentation
• Determine the appropriate codes to assign for the services and diagnoses
• Abstract statistical data from the patient record and enter information following the facility guidelines
• Utilize coding resources along with any other applicable reference material available
• Ensure accuracy in coding for all of the assigned services
• Review documentation of various providers
• Determine accurate coding for all medical services and surgical procedures from available medical records within electronic medical records
• Determine all appropriate diagnoses and assign the most specific ICD-10 code

Skills: ICD-10 Coding, PCS Procedures, DRG Assignment, Record Review, Data Abstraction, Coding Accuracy, Provider Documentation, Surgical Coding

• Assist other departments in coding and reimbursement issues
• Follow all HIPAA regulations and uphold a higher standard around privacy requirements
• Develop trusted relationships with the client contacts and other team members around the globe
• Adhere to all internal competencies, behaviors, policies and procedures to ensure efficient work processes
• Completes all assigned work promptly based on internal, client and/or payer standards
• Maintain at least a 95% accuracy rate at all times
• Maintain productivity standards, tracking and deadlines
• Maintain and complete accurate productivity and tracking logs
• Keep all equipment updated and active on the internet
• Comply with established facility policies and procedures

Skills: Coding Support, HIPAA Compliance, Client Relations, Policy Adherence, Work Accuracy, Productivity Standards, Record Tracking, System Maintenance

• Working experience in coding, medical records, claims or billing area
• Experience with International Classification of Diseases (ICD-10 and ICD-9-CM), Current Procedure Terminology (CPT4), and Healthcare Common Procedure Coding System (HCPCS) coding systems, and other related documentation requirements
• Demonstrated ability to understand the clinical content of a health record
• Knowledge of and experience in medical record department functions, diagnosis-related groups, and the prospective payment system
• Demonstrated knowledge of and skill in word processing, spreadsheet and database PC applications
• Experience in outpatient or inpatient coding in Medicare, Medicaid, and third-party liability billing areas
• Must complete an accredited Health Information Management program
• Working experience in inpatient coding
• Must have RHIA, RHIT, and/or CCS, CIC certification
• Strong communication, analytical and research skills with a keen attention to detail
• Detailed understanding of legal and policy directives pertinent to coding

Qualifications: BS in Health Information Technology with 6 years of Experience

• Experience in inpatient coding in an acute care hospital, teaching facility, or trauma center
• Experience and proficiency in coding professional physician service record types utilizing ICD-10-CM, PCS, CPT, DRG classification
• Extensive knowledge of reimbursement methodology, federal, state, and payor coding, documentation, and billing requirements
• Proficient at writing compliant physician queries in accordance with AHIMA Compliant Query Practice Brief
• Demonstrated ability to understand the clinical content within medical record documentation
• Demonstrated track record of maintaining acceptable quality standards of 95% accuracy rate and acceptable productivity standards
• Advanced knowledge of medical terminology, anatomy and physiology, disease process, pharmacology, and complex surgical procedures
• Knowledge of various coding and abstracting applications, electronic health records, platforms, Microsoft Windows and Microsoft Office
• Ability to work independently in a multi-task remote environment
• Effective written and verbal communication skills
• Excellent decision-making and problem-solving skills
• Ability to work in a team environment
• Ability to maintain confidentiality according to company and client policy and to act in accordance with that policy while engaging in all work assignments

Qualifications: BS in Medical Coding and Billing with 8 years of Experience

• Experienced in coding in a hospital setting 
• Demonstrated complex diagnostic and procedural inpatient coding experience in a computerized/electronic environment
• Working experience in Computer/data entry
• Strong written and verbal communication skills
• Able to work independently in a remote setting, with little supervision
• Working experience in Outpatient coding in an acute care setting
• Must have Certified Coding Specialist (CCS) (AHIMA) and Certified Coding Associate (CCA) (AHIMA)
• Inpatient coding experience in an acute healthcare or inpatient rehabilitation setting or progressive coding experience internally
• Must have formal training in PCS coding

Qualifications: BS in Health Information Management with 3 years of Experience

• Must have RHIT or RHIA certification
• Prior coding experience will be considered
• Ability to complete an ICD-10-CM/CPT Coding Test
• Experience in working with electronic medical records (EMR)
• Prior hospital coding experience 
• Demonstrate good written and verbal communication skills
• Ability to work independently and follow instructions
• High degree of analytical skills to compile, interpret and utilize data
• Knowledge of medical terminology, anatomy and physiology 
• Must have ICD-10-CM, ICD-10-PCS, and CPT coding knowledge
• Proficient in computer use and software applications (encoder, 3M)

Qualifications: BA in Healthcare Administration with 5 years of Experience

• Experience in complex diagnostic and procedural inpatient coding
• Skill in completing assignments accurately and with attention to detail
• Ability to analyze, organize and prioritize work under pressure while meeting deadlines
• Ability to process and handle confidential information with discretion
• Ability to work independently and/or in a collaborative environment
• Hospital coding experience with knowledge of data quality measures, DRGs, Prospective Payment Systems and APCs
• Knowledge of anatomy, physiology, ICD-9-CM and CPT-4 coding
• Ability to work independently with minimal direct supervision and cooperatively within a team environment
• Ability to communicate effectively (oral and in writing) and interact with customers to meet their needs
• Ability to handle interruptions and adapt to changes in workload and work schedule
• Ability to set priorities, make effective decisions
• Ability to recognize and deal with problematic situations and to prioritize

Qualifications: BA in Medical Records Administration with 7 years of Experience