Summary
Possesses the knowledge and skills to thoroughly review the clinical content of Outpatient, Therapy/Recurring Series, Specialty Clinic, Emergency Department/Emergency Charge Capture, Outpatient Surgery, Observation and simple Inpatient medical records and assign appropriate ICD-10-CM codes to diagnosis and CPT and HCPCS codes to all procedures or physician services for optimal reimbursement.
Principal Job Functions
- *Commits to the mission, vision, beliefs and consistently demonstrates our core values.
- *Studies and analyzes the clinical content of a medical record.
- *Assigns and sequences diagnosis and procedure codes appropriately to arrive at the correct DRG or APC assignment.
- *Enters coding information into the computer system for reimbursement use by Patient Financial Services for submitting patient's bills.
- *Maintains a thorough and updated knowledge of Clinical Coding Guidelines, Fiscal Intermediary directives, Coding Compliance standards and Local Medical Review Policies.
- *Instructs other hospital personnel on appropriate medical necessity needed for coding accurately.
- Assists with peer review auditing activities for accuracy and compliance.
- *Maintains strict confidentiality regarding patient information.
- *Works as a team member to ensure that all coding types meet or exceed the established quality standard of 95% coding accuracy while meeting or exceeding productivity standards set forth by the department leadership.
- Abides by the Code of Ethics and the Standards of Ethical Coding as set forth by the American Health Information Association (AHIMA) and adheres to Official Coding Guidelines.
- Adheres to relevant policies, procedures, regulations and expectations of BryanHealth.Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.
- Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.
- Participates in meetings, committees and department projects as assigned.
- Performs other related projects and duties as assigned.
(Essential Job functions are marked with an asterisk “*”).
Required Knowledge, Skills and Abilities
- Knowledge of anatomy, physiology, pharmaceuticals, medical terminology, disease process and ICD-10 and CPT Coding.
- Knowledge of computer hardware equipment and software applications relevant to work functions.
- Ability to meet high standards of work accuracy and productivity.
- Ability to prioritize work and seek assistance when appropriate.
- Ability to communicate effectively both verbally and in writing.
- Ability to perform crucial conversations with desired outcomes.
- Ability to establish and maintain effective working relationships with all levels of personnel and medical staff.
- Ability to problem solve and engage independent critical thinking skills.
- Ability to maintain confidentiality relevant to sensitive information.
- Ability to prioritize work demands and work with minimal supervision.
- Ability to maintain regular and punctual attendance.
Education and Experience
High school diploma or equivalency required. Class work in ICD-10-CM and CPT Coding procedures required. Certification as a Certified Coding Specialist-Professional (CCS-P) or Certified Professional Coder (CPC)required. Certified Coding Associate (CCA)or Certified Coding Specialist (CCS) preferred. Minimum of one (1) yearfacilitycoding experience in a medical environment required.
Physical Requirements
(Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.)
(DOT) – Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.#LI-RH1