Job Description

*This position is remote, and the candidate must reside in Pennsylvania or New Jersey*

JOB SUMMARY

• Reviews patient records, assigns diagnostic and procedural codes, performs related functions and participates in Performance Improvement activities.

ESSENTIAL FUNCTIONS

DIAGNOSTIC CODING OF ALL MEDICAL RECORDS REPORTED ON PATIENT BILLS

• By coding all diagnoses, treatments, and procedures according to the appropriate classification system for the category of patient encounter
• By accurately coding all inpatient records in accordance with ICD-10 CM/PCS coding rules and guidelines in a timely manner with a 95% accuracy rate
• By following approved coding conventions, assigns diagnostic and procedural codes to inpatient records
• Reviews AHA Coding Clinic and demonstrates the ability to accurately apply new coding guidelines.
• Researches new diagnostic and procedure codes as required performing the coding function.
• Informs coding supervisor of trends and opportunities for improvement in clinical documentation.
• Works collaboratively with other coders.
• Adheres to the American Health Information Management’s Code of Ethics.

LOCATES MEDICAL RECORDS THAT REQUIRE CODE ASSIGNMENT

• By searching master patient index; identifying location of existing patient records and obtaining the documentation required for code assignment.

MAINTAINS MEDICAL RECORDS OPERATIONS

• By following policies and procedures; reporting needed change

RESOLVES MEDICAL RECORD DISCREPANCIES

• By acting as a resource to other staff on coding issues
• By assisting the physicians with documentation improvement via the diagnostic query form
• By collecting and analyzing information

MAINTAINS HISTORICAL REFERENCE

• By abstraction and data entry of all inpatient records into the Good Shepherd Hospital computer system for clinical and financial purposes
• By abstracting and coding clinical data, such as diseases, procedures, using standard classification systems.
• By providing DRG/CMG forecasting information to Nurse Liaison as needed.
• By accurately assigning the correct principal diagnosis on LTCH and rehab accounts.
• By performing weekly/bi-weekly concurrent chart reviews for any potential DRG/CMG changes during the patient stay.
• By coding all discharged charts timely and accurately

PROVIDES MEDICAL RECORD INFORMATION

• By providing codes for billing and answers questions from hospital staff
• By assisting physicians and other direct patient care professionals in questions regarding level of detail for diagnostic entries, according to the organization’s guidelines

MAINTAINS THE STABILITY AND REPUTATION OF THE HOSPITAL

• By complying with legal requirements.

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

• High School Diploma required
• Completion of the AHIMA independent study program preferred

Work Experience

• 2-4 years of inpatient coding experience utilizing ICD-9-CM and/or ICD-10-CM/PCS required

Licenses / Certifications

• RHIA, RHIT, CCS, CPC, active member in AHIMA preferred

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