HIM Coding Specialist

Job Summary

The HIM Coding Specialist performs coding and abstracting for inpatient and outpatient medical records accurately and in a timely manner to optimize reimbursement for all payer classes. This role also works billing edits in the EMR and claim scrubber and is normally scheduled Monday through Friday.

Essential Duties

• Support and promote an environment aligned with the hospital’s mission, vision, and values.
• Analyze patient records for principal and secondary diagnoses and procedures, then assign appropriate codes according to established guidelines.
• Maintain current knowledge of HIPAA and best practices regarding medical records.
• Abstract required data for patient records.
• Ensure timely data entry of codes.
• Facilitate the flow of medical record data to support accurate reimbursement, data collection, and clinical data analysis.
• Represent Health Information Management in team settings and meetings as directed.
• Review charges for accuracy and validity.
• Add charges as needed for billing accuracy.
• Collaborate with physicians regarding diagnoses and procedures.
• Follow up with providers when documentation is insufficient or unclear.
• Ensure documentation supports medical necessity guidelines.
• Organize and prioritize work to meet turnaround and productivity expectations.
• Recognize and report inconsistencies and discrepancies in medical record documentation.
• Communicate with other clinical team members regarding documentation issues.
• Use coding reference materials, including coding books and the 3M encoder, efficiently.
• Follow hospital and department policies, including release of information, amendment of medical records, and other legal requirements.
• Assist in orienting and training new staff.

Additional Information

• Monday through Friday schedule
• Requires compliance with HIPAA and patient confidentiality standards
• Physical demands include vision, hearing, repetitive motion, and environment-related requirements