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The coder is responsible for applying appropriate classification standards to medical records and assigning accurate ICD-10-CM/PCS codes for diagnoses and procedures. They must also resolve documentation discrepancies through provider queries and perform quality assessments to ensure coding accuracy.
Duties and Responsibilities:
Apply appropriate coding classification standards and guidelines to medical record documentation for accurate coding.
Submit necessary provider queries to resolve documentation discrepancies.
Perform quality assessment of records, including verification of medical record documentation.
Responsible for researching errors or missing documentation from medical records to provide accurate coding processes.
Abstracts and assigns the appropriate ICD-10-CM/PCS codes for all diagnoses and procedures performed in the outpatient and inpatient settings as applicable.
Knowledge, Skills, and Abilities:
Must have inpatient medical and surgical coding experience, including complicated procedures.
Must have experience coding for trauma centers and teaching facilities.
Must be able to pass a coding assessment.
Must be proficient in Microsoft Office, including Excel, Outlook, and Teams.
Must have the ability to multi-task and excellent communication skills.
Must maintain a 95% QA accuracy rate and meet production expectations.
Must be able to apply official coding guidelines and Coding Clinics.
Must have experience working in a remote environment.
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