Certified Coder

Duties And Responsibilities

• Reviews chart thoroughly to ascertain all diagnoses/procedures.
• Contacts responsible physician in a professional, tactful manner, if diagnosis is not available on chart or clarification of documentation is needed.
• Safeguards diagnoses and procedures on coding summary by ensuring they are supported by the physician’s documentation.
• Ensures codes are assigned correctly and sequenced appropriately as per coding guidelines and government regulations.
• Refers chart to Director/Coding Supervisor, if there is a question regarding the diagnoses/codes.
• Utilizes computerized coding/abstracting equipment.
• Codes all diagnoses/procedures in accordance to ICD 10-CM/PCS coding principles, guidelines, and government regulations.
• Maintains 95% accuracy of principal diagnoses and procedures appropriately and/or correctly coded.
• Ensures data quality and optimal reimbursement allowable under the federal and state payment systems.
• Acts as a resource person to Hospital staff for coding and HIM issues.
• Must be familiar with all charting and coding requirements.
• Demonstrate knowledge of computer system.
• Willingly accepts additional assignments.

Requirements

• Adheres to dress code, appearance is neat and clean.
• Completes annual educational requirements.
• Maintains regulatory requirements, including all state, federal and CMS regulations.
• Maintains Hospital HIPAA requirements, policies and standards on patient confidentiality at all times.
• Consistently completes and maintains assigned duties.
• Attends Hospital and Department in-services as scheduled.
• Attends HIM Department staff meetings as scheduled.
• Works at maintaining a good rapport and a cooperative working relationship with physicians, departments and staff.
• Actively participates in the departments CQI activities.
• Communicates the mission, vision, core values of the Hospital.
• Ensures compliance with policies and procedures regarding department operations.
• Complies with all organizational policies regarding ethical business practices.