Review patient medical records and documentation to identify diagnoses and procedures.
Assign accurate and complete ICD-9-CM, CPT, and HCPCS codes based on clinical documentation and coding guidelines.
Ensure coding meets federal, state, and payer-specific requirements.
Abstract and enter coded data into electronic health records and hospital information systems.
Collaborate with clinical staff or coding team leads to clarify documentation as needed.
Maintain productivity and accuracy standards in accordance with departmental policies.
Stay current with updates to coding regulations, coding clinics, and payer guidelines.
Adhere to HIPAA regulations and all hospital confidentiality and compliance standards.
High school diploma or equivalent required; associate's or bachelor's degree in health information management or a related field preferred.
Basic knowledge of ICD-10-CM, CPT, and medical terminology.
Strong attention to detail and analytical skills.
Certified Coding Specialist (CCS) preferred or Registered Health Information Technician (RHIT) preferred.
Completion of the IRMC outpatient coding competency test.
Location
Pennsylvania, US
Employment Type
Full-time
Experience Level
Entry Level
Remote work allowed
No
Posted
1 month ago