About this role
Essential Job Functions
- Responsible for abstracting, coding, sequencing and interpreting the clinical information from inpatient, outpatient, emergency department, pro fee and clinical medical records.
- Responsible for the assignment of correct principal diagnoses, secondary diagnoses and principal procedure and secondary procedure codes with attention to accurate sequencing.
- Utilizes technical coding principals and DRG/APC reimbursement expertise to assign appropriate codes.
- Abstracts and codes pertinent medical data into multiple software programs and/or encoders. Follows official coding guidelines to review and analyze health records.
- Maintains compliance with both external regulatory and accreditation requirements, and with State and Federal regulations.
- Extracts pertinent data from the patient’s health record, and determines appropriate coding for reports and billing documents.
- Identifies codes for reporting medical services, procedures performed by physicians. Enters codes into various computer systems dependent upon the various clients.
- Track and document productivity in specified systems, maintain productivity levels as defined by the client.
- Maintain 95% quality rating
- Regularly participates in virtual meetings, training, coaching, audits, and other work-related interactions using Company-approved collaboration technology, including audio and video, as required by Company or client.
- Performs duties in compliance with Company’s policies and procedures, including but not limited to those related to HIPAA and compliance.
Key Success Indicators/Attributes
- Ability to prioritize and multi-task in a fast-paced, changing environment.
- Demonstrate ability to work in all work types and specialties.
- Demonstrate ability to self-motivate, set goals, and meet deadlines.
- Demonstrate leadership, mentoring, and interpersonal skills.
- Demonstrate excellent presentation, verbal and written communication skills.
- Ability to develop and maintain relationships with key business partners by building personal credibility and trust.
- Maintain courteous and professional working relationships with employees at all levels of the organization.
- Demonstrate excellent analytical, critical thinking and problem solving skills.
- Skill in operating a personal computer and utilizing a variety of software applications.
- Knowledge of coding convention and rules established by the AHIMA, American Medical Association (AMA), the American Hospital Association (AHA) and the Center for Medicare and Medicaid (CMS), for assignment of diagnostic and surgical procedural codes.
- Knowledge of JCAHO, coding compliance and HIPAA HITECH standards affecting medical records and the impact on reimbursement and accreditation.
Supervisory Responsibility
No
Work Environment
This job operates in an office environment. This role routinely uses standard office equipment such as computers and phones.
Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job:
- Stationary Position: Must be able to remain at a desk for prolonged periods for most of the workday.
- Operating Equipment: Constantly operates a computer, keyboard, mouse, and telephone/headset, including frequent repetitive hand/wrist motions for typing and prolonged periods of screen viewing and virtual communication.
- Visual Requirements: Requires close visual acuity to view computer screens, read documents, and analyze data.
- Cognitive Focus: Sustained concentration for problem-solving and task management, including ability to maintain concentrated attention to detail to ensure coding accuracy and compliance
- Communication: Frequently communicates with coworkers and clients via speech and hearing.
- Movement: Occasionally stands, walks, or reaches to access office equipment, files, or supplies. Light lifting of up to 10 pounds may occasionally be required.
Position Type
This position can be full-time or part-time as determined by the job requisition for the specific client assignment to which the employee is assigned.
Expected Hours of Work
Days and hours of work will depend on the specific client assignment to which the employee is assigned. This position may require long hours and weekend work to support Company or client needs.
Travel
Minimal travel required; up to 5%
Required Education and Experience
Successful completion of an AAPC or AHIMA-approved Coding Certificate Program and a minimum of two to four years of current production coding experience in both acute care and profee.
Preferred Education and Experience
N/A
Additional Eligibility Qualifications
Must have the following certificates and/or licenses: CPC, COC, CIC, RHIA, RHIT, CCS, and/or CCS-P.
Other Duties
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice. Employee may perform other duties as assigned.
IP Coder, CCS required. Experience with Level I Trauma, Transplants, Major Cardiothoracic Procedures. EPIC and CAC experience required.