Responsible for accurately and timely coding patient encounters independently following established coding, CMS regulations and hospital guidelines. Reviews outpatient (ASU/OBS) and/or inpatient medical records, accurately codes diagnostic and procedural information following coding guidelines and regulations.
1. Reviews complex medical records to identify sequence, code diagnoses and procedures according to established coding, CMS and hospital guidelines. (95%)
• Responsible for accurately coding outpatient ASU/OBS or inpatient encounters.
• Maintains productivity and quality rate according to established standards.
• Supports Clinical Documentation Improvement program.
• Ensures optimal DRG and/or ASC/APC/APG assessment.
• Works within UH Billing time frames.
• Maintains updated knowledge of guidelines and regulations affecting the UHHS Coding Department.
2. Assists with other responsibilities as needed. (5%)
*This role may encounter Protected Health Information (PHI) as part of regular responsibilities. UH employees must abide by all requirements to safely and securely maintain PHI for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace