The information described in this job description has been designed to indicate the general nature of the work performed. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this job. Responsible for the accurate coding and abstracting of all Hospital Inpatient records in accordance with established guidelines. Responsible for the accurate coding and abstracting of all Hospital Outpatient records in accordance with established guidelines. Physician Based Coder responsible for accurate and timely review and coding of office visits, procedures and surgeries for multi-specialty areas into the billing and accounts receivable system Works effectively and cooperatively within the workplace. The coder must have experience in reviewing physician documentation to assign the correct Evaluation and Management (E/M) code category and level for the service. In addition, the coder ensures that all external regulations affecting the coding process are implemented in the work course to assure compliance and consistency of coding and reduce the risk of external audits. Location/Department specific tasks and competencies may apply.
High School graduate or GED required. Coding certification courses and completion at an accredited school or relevant work experience.
Experience/TrainingMinimum of two (2) years progressive on the job experience, Three (3) years preferred. Inpatient, Outpatient, Emergency Room/Dept. and/or Professional Services, ICD-10-CM, CPT, ASA Coding and abstracting of multiple case types within the past Two (2) years required. Skills assessment examination is required for new hires. Experience in Epic Systems preferred. Certified Coding experience, including Inpatient and or Specialty coding, Outpatient, Emergency Room and Professional Services Coding preferred.
License/CertificationCertified Coder within 6 months of hire date - CPC, RHIA, RHIT or CCE Certifications. Must keep credentials/licensure current
Other QualificationsEffective verbal, written and interpersonal communication skills required. Must be able to effectively utilize Microsoft Office applications to perform work. Well developed problem solving and analytical skills required. Must be able to effectively prioritize workload amongst frequent interruptions with competing priorities. Knowledge of current coding rules and guidelines (CPT, ICD -9, ICD - 10). Familiar with chart abstracting, what information is used, and how. Must possess a basic understanding of anatomy, physiology, disease process and medical terminology. Ability to access and use coding resources. Must be able to code professional services for a wide variety of specialties. Ability to coordinate work schedule with requirements of position (may include overtime and weekend work).