Coder Noncertfied

Job Summary

Accountable for the conversion of diagnoses and treatment procedures into codes using an international classification of diseases. Requires skill in the sequencing of diagnoses/procedures in accordance with coding guidelines. Ensures that records are coded in an accurate and timely manner.

Duties and Responsibilities

• Demonstrates Competency in the Following Areas:


• Ensures that records are coded within three days of discharge, excluding weekends and holidays.


• Reviews the chart thoroughly to ascertain all diagnoses/procedures.


• Contact the responsible physician in a professional, tactful manner if the diagnosis is not available on the chart.


• Refers chart to the director, if there is a question regarding the diagnoses/codes.


• Utilizes computerized coding/abstracting equipment.


• Codes all diagnoses/procedures in accordance to ICD-10-CM coding principles and the Coding Manual.


• Meets the productivity standard of assigning codes based on account type.


• Meets quality standards of having 95% of principal diagnoses and procedures appropriately and/or correctly coded.


• Maintains 99% rate of information correctly abstracted.


• Assists with education and coding for medical necessity.


• Maintains the number of DRG/coding changes below the 3% quarterly per PRO threshold.


• Reviews coding periodicals within seven (7) days of receipt.


• Notifies the director whenever work is more than 48 hours behind the work deadline.


• Ensures data quality and optimum reimbursement allowable under the federal and state payment systems.


• Acts as a resource person to hospital and clinic staff for coding and may provide education regarding coding changes/issues.


• Maintains a good working relationship within the department, other departments, and medical staff.


• Must be familiar with the following manuals: Administration, Health Information Management Department, Fire Safety, Emergency Management and Safety, HIPAA.


• Willing to accept additional assignments.


• Performs performance improvement functions through data collection and documentation review.

Professional Requirements

• Ensures that appearance and personal conduct are professional at all times.


• Excellent attendance record.


• Wears appropriate clothing for job functions. Wears ID badge.


• Works at maintaining a good rapport and a cooperative working relationship with physicians, administration, and staff.


• Represents the organization in a positive and professional manner in the community.


• Maintains patient confidentiality at all times.


• Complies with all organizational policies regarding ethical business practices.