Collects, reviews, retrieves, and codes inpatient medical record data by carefully reviewing and analyzing documentation to assign appropriate ICD-10 codes for compliance, statistical reporting, clinical research, clinical care analysis, provider profiling, and optimal reimbursement.
Responsibilities include reviewing the entire electronic medical record for pertinent diagnoses and procedures, assigning diagnosis and procedure codes on inpatient records in accordance with organization guidelines, using ICD-10-CM and ICD-10-PCS coding methodologies and official coding guidelines, and querying physicians to clarify documentation as needed.
Also performs abstraction of clinical and demographic data, supports the documentation improvement program using 3M software, and communicates with the Clinical Documentation Specialist regarding DRG assignment.
Additional duties may be assigned as needed to support department or hospital operations.
Education
- High school diploma or GED required
- Associate degree preferred
- Bachelor's degree preferred
Experience
- 3 years of medical coding required
- 3 years of inpatient coding preferred
Licenses and Certifications
- Certified Professional Coder (CPC) upon hire required, or
- Certified Coding Associate (CCA) upon hire required, or
- Certified Coding Specialist (CCS) upon hire required, or
- Registered Health Information Technician (RHIT) upon hire required, or
- Registered Health Information Administrator (RHIA) upon hire required, or
- Certified Professional Coder Apprentice (CPC-A) upon hire required
Knowledge and Skills
- Knowledge of ICD-10
- Knowledge of medical terminology, anatomy, and physiology
- Basic computer skills
Benefits
- Comprehensive health benefits
- Retirement savings plan
- Paid time off (PTO)
- Education assistance
- Financial education and support, including DailyPay
- Expanded paid parental leave
Location
Pennsylvania, US
Employment Type
Full-time
Experience Level
Intermediate Level
Remote work allowed
No
Posted
1 month ago