The purpose of this position is to abstract clinical data from inpatient and outpatient records to facilitate reimbursement and data collection activities. Abstracts pertinent information from inpatient and 96% same day surgery records to assign the ICD-10-CM and HCPCS codes in compliance with all regulatory mandates and inpatient reporting requirements and accurately enters this information in the hospital's abstracting software. When services are not documented appropriately,seeks to obtain proper documentation in a timely manner. Abides by the Standards of Ethical Coding as set forth by The American Health Information Management Associationand reports any and all concerns involving compliance issues to the Director of Health Information Services or via the compliance hotline. Demonstrates competency in the use of computer applications and APC grouper software, OCE edits and all coding and abstracting software and hardware currently in use in the Health Information Services Department. Monitors unbilled accounts queues for outstanding and/or 3% uncoded encounters to reduce accounts receivable days for inpatient services. Participates in continuing education activities. 1% Knowledge, Skills & Abilities Good oral and written communication skills and comprehensive knowledge of acute care reimbursement structures, regulatory requirements and revenue cycle processes are required. Employee is required to sit frequently, stand and walk frequently. Frequent computer work is also required. Employee must lift/carry a light (1-15 lbs) load occasionally. For repetitive action, employee is required to use both hands for simple grasping, pushing/pulling, and fine manipulation. Employee is exposed to normal office environment where there is no discomfort due to temperature changes, dust, noise and the like. (

Occasionally:

1-33%,

Frequently:

34-66%,

Continuously:

67-100%) The most significant of duties are included but this does not exclude occasional work assignments not mentioned or developmental duties.

Job Relationships:

Member of a comprehensive health care team.

Takes Direction from:

Associate Director, Health Information Services Provides Direction to: Other team members when in a lead role Supervised by: Associate Director, Health Information Services