Responsible for assigning diagnostic and procedure codes accurately to inpatient encounters based on documentation in the electronic medical record, while maintaining compliance with established rules and regulatory guidelines.
Key responsibilities include:
- Reviewing medical record documentation and abstracting data into the encoder and EHR
- Determining principal/final diagnosis, co-morbid conditions, complications, secondary conditions, and procedures
- Assigning accurate ICD-10-CM and ICD-10-PCS codes
- Querying physicians when diagnoses or procedures need clarification
- Maintaining coding quality, productivity, and abstracting accuracy standards
- Supporting the reduction of uncoded accounts and timely completion of coding queue work
- Following AHIMA ethical coding standards and official coding guidelines
Requirements & Qualifications
Education
- Associate’s degree or higher in a CAHIIM-accredited program, or an additional two years of relevant experience in lieu of degree
Experience
- One year of relevant inpatient coding experience, or successful completion of the Houston Methodist Coding Apprentice Program or Outpatient to Inpatient Coder Transition Program
Certifications
- RHIT (Certified Health Information Technician)
- RHIA (Registered Health Information Administrator)
- CCS (Certified Coding Specialist)
Skills and Knowledge
- Knowledge of coding classification systems, DRG and APC systems, official coding guidelines, and coding compliance
- Working knowledge of medical terminology, anatomy, and physiology
- Experience with electronic medical records and imaging systems preferred
- Proficiency with electronic encoder applications preferred
- Strong PC skills and ability to use common office software, coding software, and abstracting systems
- Effective communication skills with patients, physicians, family members, and coworkers
- Ability to read, write, and speak English proficiently
Location
Louisiana, US
Employment Type
Full-time
Experience Level
Entry Level
Remote work allowed
No
Posted
3 weeks ago
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