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 Code diagnostic and procedural information from the record using ICD-10-CM/PCS and

CPT-4/HCPCS

classification systems. Utilize a computerized encoding system to facilitate accurate coding. Sequence diagnoses and procedures by following the ICD-10-CM, Uniform Hospital Data Set, Medicare, Medicaid, and other fiscal intermediary guidelines. Work cooperatively with the medical staff and other health care 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. Ensure 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. Complete and verify diagnostic and demographic information. Enter patient information into computerized inpatient and outpatient medical record databases. Ensure accuracy and integrity of medical record abstract data prior to billing interface and claims submission. Routinely code Emergency Department records and enter E&M charges the majority of productive time. Meet productivity and quality standards for emergency department coding routinely. Code inpatient, outpatient surgery and ancillary records as determined by Coding Operations Manager. Provide compliance/documentation education sessions to physicians and hospital staff as requested. Investigate, respond to, and communicate information regarding coding, documentation, and compliance questions relating infusions and injections performed in the Emergency Department and OBV. Charge capture for Observation, Emergency Department. Consistently maintain established productivity requirements and maintain a 96% or greater accuracy rate. Attend other continuing education functions as necessary to maintain credentials, regardless of whether the educational programs are supported by the Department budget.

Education and Experience Education:

One of the following credentials are required - CCS, CPC, COC, RHIA, RHIT. Successful completion of a coding certificate program with AHIMA approval status is preferred.

Experience:

Four or more years recent experience coding in an acute hospital setting required with coding ability demonstrated via a skills assessment. Must be able to operate or utilize fax machine, copy machines, microfiche reader/printer and Windows-based computer functions. High School or better. Registered Health Info Ad Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.