Responsible for coding inpatient medical records, including diagnoses and operative and diagnostic procedures, using current ICD coding systems and entering coded information into an automated grouper system.
Responsibilities
- Assign and record accurate ICD codes for all diagnoses, procedures, and operations as documented by the attending physician.
- Ensure all factors needed for accurate DRG assignment are present and that diagnoses are properly ranked.
- Make appropriate contacts to obtain or clarify necessary information.
- Enter final diagnostic code numbers and narrative descriptions into an automated grouper system.
- Respond to inquiries regarding medical documentation and DRGs from hospital staff, including utilization, quality assurance, patient accounts, and risk management staff.
- Abstract information from medical records to compile reports and statistical information.
- Enter diagnosis, treatment, admission and discharge dates, length of stay, and other data into hospital-wide or regional automated databases.
Requirements & Qualifications
Required Experience
- 1-2 years of experience where the primary function was inpatient medical records coding in or for a hospital.
Education
- High school diploma or equivalency required.
- An associate degree or bachelor's degree in health information management may substitute for one year of required experience.
Licenses and Certifications
- Current certification as one of the following:
- Certified Coding Specialist (CCS) through AHIMA
- Certified Coding Specialist-Physician Based (CCS-P) through AHIMA
- Certified Professional Coder (CPC) through AAPC
Knowledge and Skills
- Thorough knowledge of current ICD diagnosis and procedure codes.
- Thorough knowledge of medical terminology.
- Strong understanding of medical record systems and operations.
- Ability to understand and code medical records accurately.
- Effective oral and written communication skills.
- Ability to use computer applications and automated systems such as spreadsheets, word processing, email, calendar, and databases.
- Ability to read, write, speak, understand, and communicate in English sufficiently to perform essential duties.
- Strong thoroughness, sound judgment, tact, discretion, initiative, and accuracy.
Location
New York, US
Employment Type
Full-time
Experience Level
Associate
Remote work allowed
No
Posted
2 weeks ago
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