General Summary Collects, reviews, retrieves and codes data by careful review and analysis of documentation of inpatient medical records, assigning the appropriate ICD-10 codes for the purposes of compliance with regulations, statistical compilation, clinical research, clinical care analysis, provider profiling and optimal reimbursement.

Duties and Responsibilities Essential Functions:

Reviews entire current electronic medical record for pertinent diagnoses and procedures. Assigns diagnoses and procedure codes on inpatient records in accordance with established organization guidelines. Uses ICD-10 CM and PCS coding methodologies following Official Guidelines for Coding and Reporting using encoding software. Queries physicians to clarify documentation needed for coding purposes per established departmental policy. Performs abstraction of clinical and demographic data as pertinent to the account requirements. Participates in documentation improvement program using 3M software and communicating with Clinical Documentation Specialist regarding DRG assignment. Performs other duties that may be assigned by authorized personnel or as required to meet emergency needs of the department or Hospital.

Common Expectations:

Maintains job specific standards and expectations relative to productivity and quality. Maintains established policies and procedures, objectives, quality assessment and safety standards. Participates in educational programs and in-service meetings. Maintains professional growth and development and professional credentials. Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.

Qualifications Minimum Education:

High School Diploma or GED Required Associates Degree Preferred or Bachelors Degree Preferred Work Experience:

3 years medical coding Required 3 years inpatient coding

Preferred Licenses:

Certified Professional Coder Upon Hire Required or Certified Coding Associate Upon Hire Required or Certified Coding Specialist Upon Hire Required or Registered Health Information Technician Upon Hire Required or Registered Health Information Administrator Upon Hire Required or Certified Professional Coder Apprentice Upon Hire Required Knowledge, Skills, and Abilities:

Knowledge of ICD-10 Knowledge of medical terminology, anatomy, and physiology Basic computer skills

Benefits Offered:

Comprehensive health benefits Retirement savings plan Paid time off (PTO) Education assistance Financial education and support, including DailyPay Expanded Paid Parental Leave For additional details: Benefits & Incentives | WellSpan Careers (joinwellspan.org)