Senior Coding Specialist

Summary

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.

Essential Duties and Responsibilities

These duties and responsibilities described below represent the general tasks performed on a daily basis; other tasks may be assigned.

• 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

• Ensure the accuracy and integrity of medical record abstract data prior to billing interface and claims submission

• Routinely code inpatient records to meet productivity and quality standards for inpatient coding

• Code outpatient, emergency department, and outpatient diagnostic records as determined by Coding Operations Manager

• Consistently 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

• Attend required hospital-wide orientations, meetings, and in-services

• Demonstrate a commitment to flexible work scheduling when necessary

Summary of Other Job Duties and Expectations

• Adhere to the Service Excellence Standards and Expectations at Chesapeake Regional Medical Center

• Exhibit excellent customer relations to patients, visitors, physicians, and co-workers

• Exhibit courteous communication skills and an ability to work with others, exercising good judgment in performance of job duties

• Demonstrate courtesy, compassion, and respect to others in adherence of the hospital's philosophy and policy for promoting positive work and customer environments

• Work as a team to continuously improve work quality

• Demonstrate a commitment to flexible work schedules when it is necessary to ensure patient care

• Present self in a positive manner as reflected by personal attire, etiquette, and behavior

Supervisory Responsibilities

Reports to:
HIM Coding Operations Manager

Supervises:
N/A

Responsibilities:
N/A

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and Experience

Minimum Required Education:
Completion of a Health Information Management program with AHIMA approval status or coding program with AAPC

Preferred Education:
N/A

Experience:
4+ years recent experience coding in an acute hospital setting required; coding ability will need to be demonstrated via a skills assessment

Certificates, Licenses, Registrations

Certification in RHIA or RHIT and CCS or CIC is required. In addition, also prefer outpatient coding certifications through AHIMA and AAPC.