POSITION SUMMARY 

To be fully engaged in providing timely, complete, and accurate code assignment and data collection for quality clinical analysis and revenue enhancement.

PRIMARY ACCOUNTABILITES 

1. Uphold regulatory compliance by assigning and sequencing accurate ICD 10 codes to inpatient medical records as per coding guidelines demonstrating behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities.
2. Validates the accuracy of codes assigned by the computer assisted coding software, recognizing inappropriate application of clinical coding regulations/guidelines, and revising the codes assigned based on expert subject matter knowledge and provider documentation.
3. Literacy and proficiency in computer technology, particularly related to health information and coding applications utilized for daily job performance, are essential.
4. Interpret clinical documentation to ensure codes reported are clearly and consistently supported by the health record.
5. Examine and ensure that the MS-DRG, APR-DRG, SOI, and ROM of each inpatient encounter is compatible and compliantly optimized.
6. Request clarification from the provider when there is conflicting, incomplete, or incorrect information in the health record regarding a significant reportable condition or procedure or other reportable data element collaborating with the Clinical Documentation Specialists regarding concurrent and post-discharge queries to the providers, ensuring physician responses to queries are reflected in the code assignment.
7. Abstract relevant information accurately and completely into the computer assisted coding application, including but not limited to present on admission indicators, 
   consulting physicians/dates, surgeons/dates, and birthweight of infants. Verify and revise according to documentation in the medical record the correct discharge disposition of encounters coded.
8. Confirm the admission status ordered by the physician in the medical record documentation and the registration status of the encounter are compatible.
9. Communicates professionally identified discrepancies, documentation issues, denial management issues and coding concerns in the medical record to the appropriate department and/or leader.
10. Stays up to date with regulatory changes by completing all mandatory educational accountabilities in a timely manner.
11. Maintain coding quality and productivity as per departmental standards.
12. Attends department meetings and other inpatient coding sessions as scheduled.
13. Accurate and ethical time and attendance recording ensure that non-productivity logs are completed and submitted by the deadline set.
14. Provide departmental coding coverage by cooperating with occasional schedule revisions and overtime requests when staffing needs arise assisting with maintenance of discharge not final coded (DNFC) departmental goals.
15. Maintain and observe patient confidentiality as outlined in the National Patient Safety Goals and HIPAA guidelines always protecting the confidentiality of the health record 
    and refusing to access protected health information not required for coding-related activities.

MINIMUM QUALIFICATIONS 

• Education: High School Diploma
  
• Work Experience: 4 Years Inpatient Coding Experience
  
• Licensure: N/A
  
• Certification: AHIMA or AAPC Inpatient Coding Certification
  
• Work Experience in lieu of Certification: 8 Years Inpatient Coding Experience
• Skills/Knowledge/Abilities:
  • Competent in understanding medical terminology. 
  • Advanced understanding of anatomy and physiology. 
  • Utilize critical thinking skills and formulate logical decisions to apply clinical coding guidelines to health record documentation.
  • Strong written and oral communication skills for professional interaction.
  • Excellent computer and telephone skills.
  • Must be detail and accuracy oriented.
  • Ability to coordinate and use logical reasoning to facilitate daily workflow assignments.
  • Ability to work independently maintaining focus on scope of work assigned.

PREFERRED QUALIFICATIONS 

• Work Experience: 6 Years Inpatient Coding Experience

PHYSICAL REQUIREMENTS

• Majority of time involves sitting or standing; occasional walking, bending, and stooping.
• Long periods of computer time or at workstation.
• Light work that may include lifting or moving objects up to 20 pounds with or without assistance.
• May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise.
• Communicating with others to exchange information.
• Visual acuity and hand-eye coordination to perform tasks.
• Workspace may vary from open to confined, onsite, or remote.
• May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle.