Certified Coder

Responsibilities:

The Certified Coder accurately codes all diagnoses and procedures in the medical record and abstracts relevant information from these medical records. The Certified Coder uses this information to form the basis of a patient information system relating to the clinical care of the patient.  The Certified Coders schedule is:

Essential Functions:

• Reviews medical records to apply codes for diagnoses, operative, and diagnostic procedures according to the current edition of the International Classification of Diseases and Operations, and in the HCPCS CPT-4 Coding System in order to ensure information for billing and data collection purposes is accurate, utilizing the hospital’s coding software.
• Maintains an average productivity rate of 2 inpatient charts per hour and 7 outpatient charts per hour.
• Provides Coding Manager with productivity statistics and quality results on a bi-weekly basis.
• Abstracts relevant information from each medical record using UHDDS definitions for input into Meditech EMR, to provide data for the processing of reports.
• Reviews incomplete record files for the completion of diagnostic information by the physician and the application of codes by the coding technician.
• Participates in second level chart reviews, auditing peer coded medical records to ensure completeness, quality, and accuracy of coded medical records.
• Works closely with Clinical Documentation Improvement Specialists to retrieve pertinent documentation from clinicians to ensure quality, consistency and integrity of medical record documentation.
• Possesses a good level of understanding of the DRG Validation procedure and DRG information for inpatient coding and possesses a good understanding of CPT guidelines for outpatient coding, assuring that the accuracy rate of 95% is maintained.
• Performs DRG validations on all appropriate charts to insure that these charts will meet all requirements of outside review and regulatory agency requirements.
• Able to work at the hospital or remotely and maintain accountability and consistency of assigned work.
• Alerts Coding Manager of any charts that may be a potential liability to the Hospital.
• Participates in all performance improvement functions and department meetings assigned by the Coding Manger and HIM Director.
• Participates in continuing education programs specific to Coding and Abstracting functions, as assigned by the Coding Manager.
• Participates in continuing education programs specific to Coding and Abstracting functions, as assigned by the Coding Manager.

Education and Experience:

High School Diploma and 1-3 years of experience – required

Associates Degree, health record technology program equivalent approved courses of AHIMA or comparable work experience, minimum of one year experience in coding, abstracting, and gathering statistical data in a health care setting. – Preferred

License/Certification:

CC-A or CCS – Required within 1 year of hire

RHIA or RHIT – Preferred upon hire

Benefits: 
We offer a competitive salary and comprehensive benefits to part-time and full-time employees including:  

• Medical, dental, & vision insurance available 1st of the month after start date  

• Wellness and gym discounts & free cardiac rehab gym  

• 403B  

• On-site discounted childcare center  

• Paid time off  

• Sick time for full time employees  

• Tuition assistance  

• Free life insurance for full time employees  

• Long term disability for full time employees  

• Short term disability  

• Employee referral bonus  

• Identity theft insurance  

• Pet Insurance  

• Flexible spending accounts  

• Employee discount program  

• Employee Assistance Program   

• Free parking