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Summary

The Coding Specialist is responsible for accurately assigning and sequencing ICD diagnostic and procedural codes and/or CPT procedural codes to inpatient and outpatient records.

Essential Duties and Responsibilities

+ Code diagnostic and procedural information from the record using ICD and CPT/HCPCS classification systems

+ Utilize a computerized encoding system to facilitate accurate coding

+ Sequence diagnoses and procedures by following the ICD, Uniform Hospital Data Set, Medicare, Medicaid, and other fiscal Intermediary guidelines

+ Work cooperatively with the medical staff and other healthcare professionals in obtaining documentation to complete medical records and ensure quality coding

+ Select the APC for each outpatient visit, ensuring coding compliance based on approved coding guidelines and conventions

+ Abstract medical data from the record to complete a discharge abstract on each inpatient, ambulatory surgery, emergency room, outpatient, and ancillary visit, completing and verifying diagnostic and demographic information

+ Enter patient information into computerized inpatient and outpatient medical record databases

+ Ensure the accuracy and integrity of medical record abstract data prior to billing interface and claims submission.

+ Code outpatient, emergency department and outpatient diagnostic records as determined by Coding Operations Manager.

+ Consistently maintain established productivity requirements and maintain a 96% or greater accuracy rate

+ Communicate and advise the Patient Accounts on coding and APC assignment and submission

+ Review chart documentation for accurate diagnosis and procedure reporting for medical necessity and other edits.

+ Complete other duties as assigned.

Summary of Other Job Duties and Expectations

+ Adhere to the Service Excellence Standards and Expectations at Chesapeake Regional Medical Center

+ Exhibit excellent customer relations to patients, visitors, physicians, and co-workers

+ Exhibit courteous communication skills and an ability to work with others, exercising good judgment in performance of job duties

+ Demonstrate courtesy, compassion, and respect to others in adherence of the hospital's philosophy and policy for promoting positive work and customer environments

+ Work as a team to continuously improve work quality

+ Demonstrate a commitment to flexible work schedules when it is necessary to ensure patient care

+ Present self in a positive manner as reflected by personal attire, etiquette, and behavior

Attend required hospital-wide orientations, meetings, and in-services

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and Experience

Minimum Required Education: Completion of an approved coding program with AHIMA or AAPC approval status

Preferred Education: N/A

Experience: 3+ years recent experience coding in an acute hospital setting required; coding ability will need to be demonstrated via a skills assessment

Certificates, Licenses, Registrations

Qualified applicants must have one of the following certifications: CCS, CIC, COC, RHIA, or RHIT or other coding certification through AHIMA and AAPC..