The Inpatient Coder reviews the entire medical record to assign the appropriate diagnoses codes, procedure codes and corresponding DRG assignment following all UHDDS and AHA coding guidelines.
Assigns the discharge disposition, Present on Admission indicators and sequences the episodes for all procedure codes. Contacts physicians in writing as needed for clarification regarding the assignment of diagnostic and procedural codes. Collaborates with the Clinical Documentation Specialist team to ensure appropriate clinical documentation within the patient medical record to support the final coding process. Ensures established quality, productivity and process goals are met.
High School Diploma or GED (Required). 2 year / Associate Degree: Health information Management Technician (Preferred). 4 year / Bachelor's Degree: Health information Management Administrator (Preferred). Combination of relevant education and experience may be considered in lieu of degree. Non Degree Program: Completion of a Coding Program through AHIMA (Preferred)
AAPC CERTIFIED PROFESSIONAL CODER (Preferred). AHIMA Clinical Coding Specialist CCS (Preferred). AHIMA CSA (Preferred). AHIMA RHIA (Preferred). AHIMA RHIT (Preferred).
A minimum of two years experience in a health care organization performing ICD 9 CM coding and MSDRG assignment for inpatient medical records.
Thorough knowledge of Federal, State and third party payer guidelines, rules and regulations related to inpatient coding (Required).
1-3 Years Experience working with electronic coding systems, electronic health records (Preferred).
1-3 Years In depth knowledge of anatomy, physiology, pathophysiology and medical terminology (Preferred).
Excellent Communications Skills, Excellent Interpersonal Skills, General Clerical Skills, Microsoft Excel, Microsoft Word.