Coding Specialist Certified

Position Summary

The Coding Specialist Certified reviews a patient's entire medical record to ensure comprehensive coding and abstracting under the supervision of the Coding Supervisor and Manager of Health Information Management. The role requires strong knowledge of DRG methodology, ICD-10, CPT-4, and APC coding rules and principles to support quality care and reimbursement.

Responsibilities

• Review medical records for diagnoses and procedures performed.
• Identify and sequence principal and secondary diagnoses, procedures, complications, and comorbid conditions for optimal reimbursement.
• Assign ICD-10, CPT-4, and DRG codes for inpatient, outpatient, emergency room, and clinical/diagnostic records.
• Abstract data from medical records and enter coding, clinical, physician, and demographic information into the coding system.
• Release accounts for patient billing after physician completion, as required.
• Process incomplete records and clarify documentation concerns with physicians.
• Support timely chart completion, coding accuracy, and claims preparation.
• Coordinate with clinical documentation specialists and assist with radiology or medical necessity worklists when needed.
• Maintain coding accuracy and timeliness standards.
• Communicate with medical staff, hospital personnel, patients, and other departments as needed.
• Assist with training new staff and perform other related duties as assigned.