Position Summary:

This position evaluates medical records, provides clinical abstracts and assigns appropriate clinical diagnosis and procedure codes in accordance with nationally recognized coding guidelines.

Position Accountabilities:

1. Abstracts electronic or paper medical records thoroughly to ascertain all diagnoses/procedures.

2. Ensures that records are coded within 48 hours of discharge, excluding weekends and holidays, pending record completion by the physician and ancillary staff.

3. Queries responsible members of the medical staff in a professional tactful manner with any questions regarding diagnoses.

4. Coder’s diagnoses and procedures on the clinical coding summary agree with physician’s documentation in the health record.

5. Enters coded diagnoses on the Physician Problem List 98% of the time correctly.

6. Refers medical record to manager or the facility’s medical director if there is a question regarding the diagnoses/codes or medical necessity.

7. Utilizes computerized coding/abstracting equipment.

8. Codes all diagnoses/procedures in accordance to ICD-9-CM, ICD-10-CM, and CPT coding principles and the coding manual.

9. Meets productivity standards.

10. Meets quality standards of having 95% principal diagnoses and procedures appropriately and correctly coded.

11. Maintains 99% rate of information correctly abstracted.

17. Ensures data quality and optimum reimbursement allowable under the federal and state payment systems.

18. Assigns EM/Level Codes for all clinic encounters.

22. Maintains a good working relationship within the department, other departments, and medical staff.

23. Supports and maintains a culture of safety and quality.

24. Willing to accept additional assignments.

27. Completes annual education requirements.

28. Maintains regulatory requirements including all federal, state, local regulations, and accrediting organization’s standards.

29. Maintains patient confidentiality at all times.

31. Reports to work on times and as scheduled, completes work within designated time.

32. Wears identification while on duty and clock in appropriately and accurately.

33. Completes in-services and returns in a timely fashion.

34. Attends annual review and department in-services as scheduled.

35. Attends at least 3 staff meetings annually, reads and returns all monthly staff meeting minutes.

36. Represents the organization in a positive and professional manner.

37. Actively participates in quality assurance performance improvement activities (QAPI) and SQSS.

38. Complies with all organizational policies regarding ethical business practices.

39. Communicates the mission, ethics, and goals of the facility as well as the focus statement of the department.

POSITION QUALIFICATIONS:

Minimum Education: Minimum of High School Graduate but preferably credentialed. RHIT preferred.

Experience: Three to five years or more of similar hospital coding experience.

Required Certification/Registration: CPC-A, CPC

Skills:

Medical terminology, anatomy and physiology.

Able to communicate effectively in English, both verbally and in writing.

Basic computer knowledge.

Critical thinking skills.

Physical Demands

Prolonged sitting, extensive use of computer, some walking, and the ability to lift 20 lbs.

Working Conditions: Remote

Job Type: Full-time

Benefits:

• Dental insurance
• Disability insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance
• Work from home

Schedule:

• Monday to Friday

Work Location: Remote

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