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Form of workSUMMARY: Performs the process of coding and abstracting medical documentation in accordance with established ethical and clinical coding rules and regulations. Responsible for accuracy of data in the abstract to ensure compliance with regulatory agencies for AHS system wide procedures. Performs data entry, data analysis and review of medical record documentation related to coded/abstracted data and medical documentation to be in compliance with meaningful use, Joint Commission, CMS, and other regulatory standards. Performs other duties as needed.
DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE: The following are the duties performed by employees in this classification, however, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.
1. Assist with completion of reporting for OSHPD (Office of Statewide Healthcare Data).
2. Assist with reconciliation of records not finalized including the billing error worklist.
3. Coding of all diagnostic and procedure information from the medical record using ICD-CM and CPT coding classification systems for services such as ancillary, lab, radiology, etc. as directed by the manager.
4. Communicate and reports audit results as requests.
5. Completion of medical records; interacts with physicians to clarify and accurately document and or abstract patient diagnostic and procedure information.
6. Demonstrates proficiency in organizing and prioritizing all work to ensure medical records are coded in timeframes that will assure compliance with regulatory requirements and revenue cycle.
7. Enters patient information into the computerized medical record, databases, or other data entry systems as assigned, ensuring the accuracy and integrity of the medical record abstract or encounter data.
8. Optimizes hospital payment legitimately and ethically by utilizing approved coding guidelines and conventions.
9. Review medical records to identify diagnoses/procedures in assigned area of responsibility.
10. Verification and abstraction of all medical data from the medical record to complete a data abstract for assigned encounters and projects.
11. Corrects data as appropriate.
12. Ensures that all data abstracted and/or coded are consistent with guidelines outlined by regulatory, regional and local agencies.
MINIMUM QUALIFICATIONS:
Education: Associate’s Degree preferred.
Education: Courses in medical terminology, anatomy and physiology, ICD-9/10 and CPT coding conventions, and disease process within the past five years.
Education: High School Diploma.
Minimum Experience: Recent three years' experience in an acute care hospital HIM/electronic health record experience to include analysis, regulatory monitoring, release of information, vital statistics, scanning, indexing and data analysis and reporting in an EHR environment.
Preferred Licenses/Certifications or Progression in one or more of the following: Certified Coding Apprentice (CCA) (or in progress), Certified Professional Coder (CPC) (or in progress), Certified Coding Specialist (CCS) (or in progress) or Registered Health Information Technician (RHIT) (or in progress).
Required Demonstrated Proficiency: Passing HIM Coding Assessment, passing score of 80%.
PI233226879
