Under the general direction of the Manager or Lead Coder,the Coder is responsible for accurate coding of inpatient, outpatient, Emergency Room Services, Ambulatory Surgery Center, 23 hour observation diagnoses, conditions and procedures working from the appropriate documentation in the patient's health record. Classification systems include the most current versions of ICD-9 and CPT as well as other specialty systems as required.
Required: High School Diploma plus training acquired through work experience or education
Preferred: Associates Degree OR equivalent training acquired via work experience or education
Required: 1-2 years of previous job-related experience
Preferred: 3-5 years of previous job-related experience
Required: Certified Coding Associate (AHIMA) or,Certified Coding Specialist (AHIMA) or,Certified Coding Specialist Physician Based (AHIMA) or,Registered Health Information Administrator (AHIMA) or,Registered Health Information Technician (AHIMA)
Position Responsibilities: Codes diagnoses, treatments, procedures according to the appropriate classification system for the category of the patient's encounter. Assigns the diagnosis or procedures code with an accuracy rate of 97%or better with progression to and maintenance of 98% within the work standard. Refers accounts with ambiguous documentation and other related coding issues to the Lead Coder for review and validation. Participates in all external coding compliance studies, UHC benchmark studies and Joint Comission core measure audits. Provides peer review as needed and participates in department's total quality improvement process. Promotes public relations through prompt and courteous service and responds to coding inquires. Fosters respect for patient privacy by guarding confidentiality in all phases of the work performed. Trains students and new employees in coding practices and may be asked to oversee and monitor coding practice.