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+ JOB DESCRIPTION DETAILS

+ Reports to :

+ HIM Coding Manager

+ Job Summary :

+ Codes and abstracts outpatient medical records in accordance with established coding conventions and guidelines.

+ Education :

+ Associate's or Bachelor's degree in Health Information Management (HIM) or Coding, preferred. Position requires formal working knowledge equivalent to a two or four year degree in HIM or Coding.

+ Registration/Certification/Licensure :

+ AHIMA Certifications (RHIA, RHIT, CCS, CCS-P)

+ AAPC Certifications (CPC, CPC-H)

+ Experience :

+ 1 year of medical coding experience in a clinical, hospital, or physician office setting

+ Possess a strong grasp of: Ambulatory Payment Classifications (APC's), all Patient Refined Diagnosis Related Groups (APR-DRGs) - Maryland, andPotentially Preventable Complications (PPCs)/Maryland Hospital Acquired Conditions (MHACS) experience, required.

+ Familiarity with Meditech and 3M Coding and Reimbursement System, preferred.

+ 360 Encompass experience, a plus.

+ Other Requirements :

+ Maintains unit-specific and hospital competencies, mandatory learning, and any clinical certifications required in accordance with the Staff Education and Training policy GA-057 and/or any other department requirements.

+ Comprehensive knowledge of Pathophysiology, disease processes, Pharmacology and Medical Terminology.

+ Ability to effectively communicate with clinical and non-clinical staff, both verbally and in writing.

+ Knowledge of HIM workflow.

+ Ability to complete and submit physician queries as appropriate.

+ Effectively communicates with clinical and non-clinical staff, both verbally and in writing, by implementing organization-wide communication techniques as a daily practice.

+ Demonstrated proficiency of computer skills necessary to effectively complete position requirements.

+ Ability to work independently and prioritize tasks producing quality work that is timely.

+ FLSA Status :

+ Non-Exempt

+ Populations Served/Patient Care Responsibilities

+ All age populations

+ TECHNICAL COMPETENCIES

+ Principle Duties and Responsibilities:

+ Reviews clinical documentation and diagnostic results to accurately extract data and assign appropriate ICD-10-CM/CPT codes for billing internal and external reporting, research and regulatory compliance.

+ Accurately assigns codes utilizing ICD-10-CM and CPT codes for inpatient and outpatient records as documented in the ICD-10-CM Official Guidelines for Coding and Reporting.

+ Assigns principal and secondary diagnosis and procedure codes using the computer system and encoder.

+ Works with the Clinical Documentation Analyst to assist in the development and improvement in the Clinical Documentation Improvement program (inpatient).

+ Contacts physicians when recognizing when further documentation clarification is needed for accurate coding and appropriately queries the physician.

+ Abstracts required data elements as instructed.

+ Establishes and maintains an outpatient coding accuracy rate of 95% or greater.

+ Establishes and maintains an outpatient coding production rate of 90% or greater.

+ Ensures HIPAA compliance at all times.

+ Abides by the standards of Ethical Coding set forth by the American Health Information Management Association (AHIMA).

+ Attends coding specific hospital meetings with the Director of HIM and/or the Coding Manager.