The Certified Coding Specialist reviews patients' entire medical records to ensure comprehensive coding and abstracting in accordance with coding rules, principles, and ethics. This role supports accurate reimbursement by assigning ICD-10, CPT-4, APC, and DRG codes, abstracting clinical information, and working closely with Health Information Management leadership.
Key responsibilities include:
- Reviewing medical records for diagnoses and procedures performed
- Identifying and sequencing principal and secondary diagnoses and procedures
- Assigning ICD-10, CPT-4, DRG, and APC codes with a 95% accuracy standard
- Abstracting medical record information into internal systems
- Entering coding, physician-related, clinical, and demographic data into computerized systems
- Releasing accounts for patient billing after physician completion, as required
- Processing incomplete records and following up with physicians for clarification
- Supporting insurance billing workflows and chart completion
- Maintaining current knowledge of coding rules, terminology, and practices
- Assisting with training and orientation of new staff as assigned
Requirements & Qualifications
Education
- Completion of a post-secondary program in medical coding, such as a certificate, diploma, or associate degree
Experience
- Current acute care experience with ICD-10, CPT, DRG, and APC coding rules and methodologies preferred
Knowledge and skills
- Knowledge of diagnostic and procedural terminology
- Understanding of medical terminology and disease processes, including anatomy and physiology
- Ability to organize work and work independently
- Basic typing and computer skills
- Strong communication skills for clarifying record questions with medical staff and other departments
Certification
- RHIT, CCS, and/or CPC required within 1 year of hire or transfer
Location
Pennsylvania, US
Employment Type
Full-time
Experience Level
Associate
Remote work allowed
No
Posted
1 month ago
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