As an Inpatient Coder, you will work under general supervision to assign diagnosis and procedure codes for inpatient encounters of moderate to high complexity levels using ICD-9 and CPT, HCPCS, and any other designated coding classification system in accordance with coding rules and regulations. Essential functions include but are not limited to:
- Reviews medical documentation for the determination and accurate assignment of all documented diagnoses and procedures.
- Assigns and sequence codes based on medical record documentation.
- Assigns appropriate discharge disposition.
- Assigns POA status and identifies HAC situations
- Abstracts and enters coded data and designated quality management data for hospital statistical and reporting requirements.
- Communicates documentation improvement (CDI) opportunities and coding issues (discrepancies, physician queries, etc.) to the appropriate personnel for follow up and resolution.
- Serves as a functional resource for entry-level coders and mentors/trains other coders as needed.
- Codes any and all types of acute care patient records (i.e., inpatient, ambulatory surgery).
- Certified Coding Specialist (CCS), and
- Minimum of three years acute care inpatient coding experience in a moderate to large size PPS facility (not critical access) is required.
- Registered Health Information Technician (RHIT), or
- Registered Health Information Administrator (RHIA) preferred.
- Needs experience coding multiple specialties and in a Clinical Documentation Improvment environment.
- Demonstrated experience writing queries and communicating clinical scenarios is also necessary.
- Experience in computerized encoding and abstracting in a Windows-based environment required.
Anthelio is the largest independent provider of "Information Technology" and "Business Process" services to hospitals,...