- Assignment Category: Not Applicable
- FTE: 1
General Summary
Collects, reviews, retrieves and codes data by careful review and analysis of documentation of inpatient medical records, assigning the appropriate ICD-10 codes for the purposes of compliance with regulations, statistical compilation, clinical research, clinical care analysis, provider profiling and optimal reimbursement.
Responsibilities
Duties and Responsibilities
Essential Functions:
- Reviews entire current electronic medical record for pertinent diagnoses and procedures.
- Assigns diagnoses and procedure codes on inpatient records in accordance with established organization guidelines.
- Uses ICD-10 CM and PCS coding methodologies following Official Guidelines for Coding and Reporting using encoding software.
- Queries physicians to clarify documentation needed for coding purposes per established departmental policy.
- Performs abstraction of clinical and demographic data as pertinent to the account requirements.
- Participates in documentation improvement program using 3M software and communicating with Clinical Documentation Specialist regarding DRG assignment.
- Performs other duties that may be assigned by authorized personnel or as required to meet emergency needs of the department or Hospital.
Common Expectations:
- Maintains job specific standards and expectations relative to productivity and quality.
- Maintains established policies and procedures, objectives, quality assessment and safety standards.
- Participates in educational programs and in-service meetings.
- Maintains professional growth and development and professional credentials.
- Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.
Qualifications
Qualifications
Minimum Education:
- High School Diploma or GED Required
- Associates Degree Preferred or
- Bachelors Degree Preferred
Work Experience:
- 3 years medical coding Required
- 3 years inpatient coding Preferred
Licenses:
- Certified Professional Coder Upon Hire Required or
- Certified Coding Associate Upon Hire Required or
- Certified Coding Specialist Upon Hire Required or
- Registered Health Information Technician Upon Hire Required or
- Registered Health Information Administrator Upon Hire Required or
- Certified Professional Coder Apprentice Upon Hire Required
Knowledge, Skills, and Abilities:
- Knowledge of ICD-10
- Knowledge of medical terminology, anatomy, and physiology
- Basic computer skills
Benefits Offered:
- Comprehensive health benefits
- Retirement savings plan
- Paid time off (PTO)
- Education assistance
- Financial education and support, including DailyPay
- Expanded Paid Parental Leave
For additional details: Benefits & Incentives | WellSpan Careers (joinwellspan.org)
