The Certified Medical Coder codes medical records utilizing ICD-10-CM and CPT-4 coding conventions. Handles confidential patient medical records and abides by HIPAA. Reviews each medical record to assure specificity of diagnoses, procedures and appropriate/optimal reimbursement for hospital and/or professional charges. This position will be coding for the hospital.

Essential Duties and Responsibilities:

Reviews the medical records and accurately code the primary/secondary diagnoses and procedures using ICD-10-CM and/or CPT coding conventions for both inpatient and outpatient accounts. Sequences the diagnoses and procedures using current coding guidelines. Abstract and compile data from medical records for appropriate optimal reimbursement for hospital and/or professional charges. Consults with and educates physicians on coding practices and conventions in order to provide detailed coding information. Communicate with nursing and ancillary services personnel for needed documentation for accurate coding. Oversees the process of retrieving patient information and obtains all missing information in patient charts Gathers patient information in the allotted time frame Protects confidential medical information following HIPAA guidelines Maintains a thorough understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques through participation in continuing education programs to effectively apply ICD- 10-CM and CPT-4 coding guidelines to inpatient and outpatient diagnoses and procedures. Maintains a thorough understanding of Health Information Management practices, standards, regulations, Joint Commission on Accreditation of Health Organizations (JCAHO), Health Care/Finance Administration (HCFA), etc Reviews and updates patients' charges on accounts when needed. Provides assistance and education to Hospital departments and clinics regarding coding matters. Assists Business Office staff with working billing edits, denials, and rebills. Works with Hospital departments on the selection of proper codes for prior authorizations needed in clinical areas such as Surgery, Case Management and Team Ortho. Assists in training new coders. Handles general clerical projects and requests Protects patient privacy and confidentiality in accordance with HIPAA and privacy laws. Ensures patient satisfaction, including troubleshooting when there is a complaint and developing process improvements to prevent reoccurrences. Demonstrates clear ownership of workplace and patient safety. Report mistakes, near misses, adverse events and quality and safety concerns. Participates in the development and implementation of safety and quality improvement activities. Other duties as may be assigned.

Job Requirements Education:

Associates degree required or High School Diploma/GED. with 2-4 years' experience in medical coding in HIM department setting.

Licensure/Certification:

Certified Professional Coder (CPC) required. Certified Inpatient Coder (CIC) preferred.

Experience:

2-4 years coding experience in a hospital setting preferred; excellent customer service skills required; ability to work quickly and accurately with confidential information; advanced computer skills in Microsoft Word and Excel; above average typing and alpha numeric data entry skills.

Physical Requirements:

Frequent sitting and long periods of data entry. Occasional bending, stooping, and reaching. Occasionally lift 25 lbs.