Coding Specialist HIM Senior

About the role

The Senior Coding Specialist is responsible for accurately assigning and sequencing ICD diagnostic and procedural codes and/or CPT procedural codes to inpatient and outpatient records.

Responsibilities

• Code diagnostic and procedural information from the record using ICD and CPT/HCPCS classification systems
• Utilize a computerized encoding system to facilitate accurate coding
• Sequence diagnoses and procedures by following the ICD, Uniform Hospital Data Set, Medicare, Medicaid, and other fiscal Intermediary guidelines
• Work cooperatively with the medical staff and other healthcare professionals in obtaining documentation to complete medical records and ensure quality coding
• Select the DRG for each inpatient discharge and APC for each outpatient visit, ensuring coding compliance based on approved coding guidelines and conventions
• Abstract medical data from the record to complete a discharge abstract on each inpatient, ambulatory surgery, emergency room, outpatient, and ancillary visit, completing and verifying diagnostic and demographic information
• Enter patient information into computerized inpatient and outpatient medical record databases
• Avoid inaccuracies and maintain established productivity requirements and maintain a 96% or greater accuracy rate
• Communicate and advise the Patient Accounts on coding and DRG/APC assignment and submission
• Assist the Coding Compliance Specialist and/or Coding Operations Manager as needed
• Fill-in for the Coding Compliance Specialist and/or Coding Operations Manager as needed
• Complete other duties as assigned

Qualifications

• Minimum Required Education: Completion of a Health Information Management program with AHIMA approval status or coding program with AAPC
• Experience: 4+ years recent experience coding in an acute hospital setting required; coding ability will need to be demonstrated via a skills assessment
• Certification in RHIA or RHIT and CCS or CIC is required. In addition, also prefer outpatient coding certifications through AHIMA and AAPC.