Knowledge of coding classification systems, DRG and APC systems, official coding guidelines and coding compliance
Knowledge of an electronic medical record and imaging systems preferred
Working knowledge of medical terminology, anatomy and physiology
Proficiency with electronic encoder application preferred
Extensive PC knowledge - must be able to work effectively in common office software, coding software and abstracting systems
ESSENTIAL FUNCTIONS
PEOPLE ESSENTIAL FUNCTIONS
Interacts and communicates effectively with members of the coding team and the appropriate stakeholders.
Participates and provides good feedback during coding section meetings and coding education inservices as well as takes initiative to assist others and shares knowledge with the appropriate stakeholders.
SERVICE ESSENTIAL FUNCTIONS
Responds promptly to internal and external customer requests. Responds promptly and appropriately to requests to code or review coded accounts for accuracy.
Initiates queries with physicians to obtain or clarify diagnoses and/or procedures as appropriate, utilizing the established physician query process.
QUALITY/SAFETY ESSENTIAL FUNCTIONS
Maintains and achieves the highest standards of coding quality by assigning accurate/ICD-10-CM/ICD-10-PCS codes utilizing an electronic encoder application in accordance with hospital policy and regulatory body guidelines.
Maintains and achieves department standards of abstracting quality by reviewing accurate discharge disposition entered by nursing and corrects if necessary in order to achieve the highest quality of entered data. Assigns and enters physician identification number and procedure date correctly in the medical record abstracting system.
Reviews medical record documentation and abstracts data into the encoder and EPIC/Electronic Health Record (EHR) to determine principal or final diagnosis, co-morbid conditions and complications, secondary conditions and procedures. Utilizes all tools/ resources for accuracy.
Complies with the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official guidelines.
FINANCE ESSENTIAL FUNCTIONS
Utilizes time effectively. Consistently codes and abstracts at departmental standards of productivity while ensuring accuracy of coding.
Supports meeting organizational goal for Accounts Receivables (AR) associated with uncoded accounts.