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General Summary

Collects, reviews, retrieves and codes data by careful review and analysis of documentation of inpatient medical records, assigning the appropriate ICD-10 codes for the purposes of compliance with regulations, statistical compilation, clinical research, clinical care analysis, provider profiling and optimal reimbursement.

Duties and Responsibilities

Essential Functions:

+ Reviews entire current electronic medical record for pertinent diagnoses and procedures.

+ Assigns diagnoses and procedure codes on inpatient records in accordance with established organization guidelines.

+ Uses ICD-10 CM and PCS coding methodologies following Official Guidelines for Coding and Reporting using encoding software.

+ Queries physicians to clarify documentation needed for coding purposes per established departmental policy.

+ Performs abstraction of clinical and demographic data as pertinent to the account requirements.

+ Participates in documentation improvement program using 3M software and communicating with Clinical Documentation Specialist regarding DRG assignment.

+ Performs other duties that may be assigned by authorized personnel or as required to meet emergency needs of the department or Hospital.

Common Expectations:

+ Maintains job specific standards and expectations relative to productivity and quality.

+ Maintains established policies and procedures, objectives, quality assessment and safety standards.

+ Participates in educational programs and in-service meetings.

+ Maintains professional growth and development and professional credentials.

+ Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.

Qualifications

Minimum Education:

+ High School Diploma or GED Required

+ Associates Degree Preferred or

+ Bachelors Degree Preferred

Work Experience:

+ 3 years medical coding Required

+ 3 years inpatient coding Preferred

Licenses:

+ Certified Professional Coder Upon Hire Required or

+ Certified Coding Associate Upon Hire Required or

+ Certified Coding Specialist Upon Hire Required or

+ Registered Health Information Technician Upon Hire Required or

+ Registered Health Information Administrator Upon Hire Required or

+ Certified Professional Coder Apprentice Upon Hire Required

Knowledge, Skills, and Abilities:

+ Knowledge of ICD-10

+ Knowledge of medical terminology, anatomy, and physiology

+ Basic computer skills

Benefits Offered:

Comprehensive health benefits

Flexible spending and health savings accounts

Retirement savings plan

Paid time off (PTO)

Short-term disability

Education assistance

Financial education and support, including DailyPay

Wellness and Wellbeing programs

Caregiver support via Wellthy

Childcare referral service via Wellthy

Quality of Life

Founded in 1741, the city of York is considered by many as the first capital of the United States. The Articles of Confederation were signed by the Second Continental Congress here in 1777. Its beautifully restored historic district is an architectural treasure. While York retains its farming and manufacturing heritage, at its heart York is a thriving cultural community that has attracted creative talent and innovative entrepreneurial investors from across the nation.

Life in York County offers affordable housing, options for higher education, a thriving arts and cultural community, historical attractions, parks and recreational resources, semi-professional baseball team, fine dining and more - within an easy drive of major East Coast cities.

York County residents can find local employment in healthcare, manufacturing, technology, agricultural and service sectors. (Patient population: 445,000)

WellSpan Health is an Equal Opportunity Employer. It is the policy and intention of the System to maintain consistent and equal treatment toward applicants and employees of all job classifications without regard to age, sex, race, color, religion, sexual orientation, gender identity, transgender status, national origin, ancestry, veteran status, disability, or any other legally protected characteristic.