Health information coding is the transformation of verbal descriptions of diseases, injuries, and procedures into numeric or alphanumeric designations. The coding process reviews and analyzes health records to identify relevant diagnoses and procedures for distinct patient encounters. Coders translate diagnostic and procedural phrases used by healthcare providers into coded procedure codes for submission of claims to payers for reimbursement. Collaboration between healthcare providers and coders is essential to achieve complete and accurate documentation and code assignment.
The role involves reviewing medical records for principal and secondary diagnoses and procedures for hospital and professional inpatient or outpatient records, ensuring compliance with provider coding regulations. Documents reviewed include laboratory findings, radiology reports, discharge summaries, history and physical, consultations, orders, progress notes, and other ancillary service treatment records. Using Encoder software, the coder determines codes and sequences them to maximize reimbursement legally, assigning the appropriate DRG.
Responsibilities include assigning codes according to hospital and professional coding guidelines, Coding Clinic directives, federal regulations, CCI coding initiatives, and CPT Assistant guidelines; querying physicians as needed to clarify documentation; assisting with training new coding staff and recommending improvements; updating historical file data by submitting claim action reports; and coordinating with other areas of the revenue cycle and external departments.
Work is typically in an office environment, requiring compliance with organizational policies. Relevant experience may combine related work and specialty training. Candidates may be considered for Coder I or Coder II roles.
Certification requirements for Coder II include AHIMA or AAPC certifications such as Certified Coding Specialist (CCS), Certified Coding Specialist – Physician-based (CCS-P), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Associate (CCA) pending upgrade within 12 months. Education requires at minimum a high school diploma or equivalent, with specialty training preferred. Minimum one year of related work experience is required.
Geisinger offers healthcare benefits from day one for full and part-time employees, fosters a collaborative and diverse work environment, and is an equal opportunity employer.
Minimum one year of related work experience or equivalent specialty training. Relevant coding certification from AHIMA or AAPC is required for higher level coder positions. High school diploma or equivalent required; specialty training program graduation preferred. Knowledge of hospital and professional coding guidelines, federal regulations, and coding software systems such as Encoder. Ability to review and analyze complex medical records and documentation. Strong communication skills to query physicians and collaborate with management and other departments.
Healthcare benefits available from day one including vision, dental, and domestic partner coverage. Supportive work environment emphasizing kindness, excellence, learning, innovation, and safety. Collaborative atmosphere and diverse workforce.
Location
Pennsylvania, US
Employment Type
Full-time
Experience Level
Entry Level
Remote work allowed
No
Posted
3 weeks ago