Responsible for ensuring diagnostic and procedure codes are assigned accurately to inpatient encounters based on documentation within the electronic medical record, while maintaining compliance with established rules and regulatory guidelines.
Key responsibilities
- Assign accurate ICD-10-CM and ICD-10-PCS codes using an electronic encoder application.
- Review medical record documentation to determine principal/final diagnosis, co-morbid conditions, complications, secondary conditions, and procedures.
- Abstract data into the encoder and EPIC/EHR.
- Initiate physician queries when diagnoses and/or procedures need clarification.
- Maintain abstracting accuracy, coding quality, and productivity standards.
- Support departmental goals related to uncoded accounts and AR timeliness.
- Participate in coding meetings and education sessions and contribute ideas for improvement.
Requirements & Qualifications
Education
- Associate's degree or higher in a CAHIIM-accredited program, or an additional two years of relevant experience in lieu of degree.
Experience
- One year of relevant inpatient coding experience, or successful completion of the Houston Methodist Coding Apprentice Program or Outpatient to Inpatient Coder Transition Program.
Certifications
- RHIT (AHIMA)
- RHIA (AHIMA)
- CCS (AHIMA)
Skills and knowledge
- Knowledge of coding classification systems, DRG and APC systems, official coding guidelines, and coding compliance.
- Working knowledge of medical terminology, anatomy, and physiology.
- Familiarity with electronic medical records and imaging systems preferred.
- Proficiency with electronic encoder applications preferred.
- Strong PC skills, including coding software, abstracting systems, and common office software.
- Ability to communicate effectively with patients, physicians, family members, and coworkers.
- English language proficiency sufficient for safe and effective job performance.
Location
Florida, US
Employment Type
Full-time
Experience Level
Associate
Remote work allowed
No
Posted
2 weeks ago
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