Coder - Certified (Inpatient)

PURPOSE STATEMENT

The Certified Coder will play a key role in converting diagnoses and treatment procedures intoICD-10, CPT and HCPCS codes. The Coder will review and accurately code office and hospital procedures for reimbursement.  

ESSENTIAL FUNCTIONS 

• Accounts for coding and abstracting of patient encounters, including diagnostic and procedural information, significant reportable elements, and complications. 
• Researches and analyzes data needs for reimbursement. 
• Analyzes medical records and identifies documentation deficiencies. 
• Serves as resource and subject matter expert to other coding staff. 
• Reviews and verifies documentation supports diagnoses, procedures, and treatment results. 
• Identifies diagnostic and procedural information. 
• Audits clinical documentation and coded data to validate documentation supports services rendered for reimbursement and reporting purposes. 
• Assigns codes for reimbursements, research and compliance with regulatory requirements utilizing guidelines. 
• Follows coding conventions. Serves as coding consultant to care providers. 
• Identifies discrepancies, potential quality of care, and billing issues. 
• Researches, analyzes, recommends, and facilitates plans of action to correct discrepancies and prevent future coding errors. 
• Identifies reportable elements, complications, and other procedures. 
• Serves as resource and subject matter expert to other coding staff. 
• Assists lead or supervisor in orienting, training, and mentoring staff. 
• Maintain and respect patient and employee privacy and confidentiality. 
• Maintain coding credentials. 
• Maintain coding education to keep current on coding guidelines and changes. 
• Maintain regular and predictable attendance. 
• Support the Medical Center’s Mission/Vision/Philosophy positively. 
• Handles special projects as requested. 

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS

• High school diploma or equivalent. 
• AHIMA or AAPC maintained credentials. 
• Knowledge of medical terminology and anatomy/physiology. 
• Professionalism, confidentiality, and organization. 
• Detail-oriented and able to self-regulate varied tasks. 
• Must be self-motivated and able to work within the established policies, procedures and practices prescribed by the hospital/clinic. 

PHYSICAL/MENTAL REQUIREMENTS

• Must be able to sit and stand, intermittent 8 to 10 hours a day.
• Must be able to use standard office equipment, including the telephone and computer keyboard.
• Continuously works under pressure of near 100% accuracy while meeting inflexible deadlines.
• Continuously utilizes manual/bi-manual dexterity, near vision, speech, and hearing.
• Frequently stands, walks, sits and utilizes eye/hand coordination and color definition.
• Occasionally reaches above shoulder, regularly required to life and/or carry up to 40 lbs.
• Occasionally walks on uneven surfaces.