Major Responsibilities:

• This role will have all responsibilities of coder I, II and III in addition to: reviews complex inpatient documentation at a highly skilled and proficient level to assign diagnosis and procedure codes utilizing ICD-10 CM/PCS. Assigns and ensures correct code selection following Official Coding Guidelines and compliance with federal and insurance regulations utilizing an EMR and/or Computer Assisted Coding software.

• Adhere to organizational and internal department policies and procedures to ensure efficient work processes.

• Responsible for coding high dollar and long length of stay cases for all patient types.

• Expertise in query guidelines, and coding standards. Follow up and obtain clarification of inaccurate documentation as appropriate.

• Serves as a subject matter expert to Coding department leaders and peers. Recommends modifications to current policies and procedures as needed to coincide with government regulations.

• Maintain continuing education by attending webinars, reviewing updated ICD-10-CM and PCS guidelines and updated coding clinics. Knowledgeable in researching coding related topics and issues.

• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines. Practices ethical judgment in assigning and sequencing codes for proper insurance reimbursement.

• Collaborates with the Clinical Documentation Improvement and Quality teams, to ensure a match in the DRG and reconciles each Medicare case with the working DRGs from a CDI perspective.

• Responsible for clinician communication related to disease processes on a clinical level to ensure accurate coding.

• Participates in payer audits and meetings by acting as a resource for coding-related audits, as requested.

• Attends meetings with clinical teams regarding updates in codes for complex specialties.

• Maintains the confidentiality of patient records. Reports any perceived non-compliant practices to the coding leader or compliance officer.

• Meets and exceeds departmental quality (95% or more) and productivity standards (100%). Achieves productivity expectations to support discharged not final billed (DNFB).

• Performs any other assigned duties since the duties listed are general in nature and are examples of the duties and responsibilities performed and are not meant to be construed as exclusive or all-inclusive. Management retains the right to add or change duties at any time.

Licensure, Registration, and/or Certification Required:

• Coding Associate (CCA) certification issued by the American Health Information Management Association (AHIMA)
• Certified Coding Specialist (CCS) certification issued by the American Health Information Management Association (AHIMA), or
• Health Information Administrator (RHIA) registration issued by the American Health Information Management Association (AHIMA), or
• Health Information Technician (RHIT) registration issued by the American Health Information Management Association (AHIMA)

Education Required:

• Associate's Degree in Health Information Management or related field.

Experience Required:

• Typically requires 3 to 5 years' experience inpatient coding in acute care tertiary facility that includes experience in revenue cycle processes, Clinical Documentation Improvement, Research and health information workflows.

Knowledge, Skills & Abilities Required:

• Advanced profiency of ICD coding guidelines. Advanced knowledge of medical terminology, anatomy and physiology.
• Excellent computer skills including the use of Microsoft office products, electronic mail, including exposure or experience with electronic coding systems or applications.
• Excellent communication (oral and written) and interpersonal skills.
• Excellent organization, prioritization, and reading comprehension skills.
• Excellent analytical skills, with a high attention to detail.
• Ability to work independently and exercise independent judgment and decision making.
• Ability to meet deadlines while working in a fast-paced environment.
• Ability to take initiative and work collaboratively with others.

Physical Requirements and Working Conditions:

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.