The coding specialist is responsible for accurately coding medical records using ICD-10-CM/PCS and CPT standards while ensuring compliance with regulatory guidelines. They must also maintain productivity standards, perform DRG/MSDRG assignments, and communicate effectively with CDI specialists.
Job Summary
Codes all requested medical records using the most accurate and appropriate ICD-10-CM/PCS, CPT codes and DRG
assignment in accordance with regulatory coding guidelines, best practices in the industry and HIA policy and
procedures. Abstract key data required from the medical information consistent with UHDDS requirements, other
regulatory and best practices. The coder will meet specified productivity and accuracy standards.
Required Skills and Experience
RHIA or RHIT or CCS credential
Minimum 2-3 years inpatient and/or outpatient coding experience in an acute care facility
I-10-CM/PCS proficiency
Computer proficiency, able to research coding questions and utilize HIA’s internal educational resources
Experience using Electronic Medical Record (EMR)
High Speed Internet accessibility via Cable (no Satellite or wireless cell based)
Independent, focused individual able to work remotely
Sound organizational, communication and critical thinking skills
Essential Job Functions Coding
All coding specialists require remote access setup in order to view the client’s EHR. Each user is assigned their own username and password. There may also be a separate username and password for the connection platform. Once an employee has been assigned to a facility, the following will need to occur.
Reviews and screen the entire medical record and accurately codes the primary/secondary diagnoses and procedures using ICD-10, CPT coding conventions
Uses TruCode encoder to ensure appropriate reimbursement and accurate DRG & MSDRG assignment
Writes appropriate, non-leading queries and communicates effectively with client CDI Specialists
Maintains 95% accuracy rate for DRG or APC and Total codes
Meets productivity standards according to client requirements
Responds well to constructive feedback during Quality Control audits
Completes action plans in a timely manner
Utilizes Quality Control audit feedback in a positive and productive manner
Submits coding questions according to HIA policy and procedure
Client Relations
Maintains professional, positive attitude with HIA and client personnel
Accurately completes the Coding Log and forwards to client at the end of the day
Maintains established office hours and begins work in a timely manner
Seeks approval for any alternate work schedules ahead of time
Follows client policies and procedures (i.e. specific coding guidelines, abstracting, rebill guidelines, etc.)
Performance and Professionalism
Maintains strict confidentiality and adheres to HIPAA guidelines
Exhibits professional demeanor at all times
Maintains communication by responding promptly to corporate office staff
Demonstrates flexibility, open mindedness, and versatility in adjusting to changing environments
Handles constructive feedback with a positive attitude
Commits to continually improving his/her job skills (i.e. educational sessions)
General Duties
Maintains accurate expenses and timesheets
Adheres to all HIA policies and procedures in the HIA Employee Handbook
Maintains current information in personnel file including CE tracking form and AHIMA membership status
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