Health System Specialist
US Department of War
Job Duties
Plan and perform audit of outpatient/inpatient medical coding and coding processes throughout BAMC to quantify coding agreement between medical record documentations and the standard ambulatory data record (SADR).
Quantify the extent of over or under medical coding on patient encounters to include outpatient, ambulatory procedures, inpatient professional services rounds, inpatient consults and inpatient.
Perform independent medical coding documentation audits, developing applicable training plans, and providing training to any BAMC employee performing documentation, coding, auditing or training functions.
Provide BAMC leadership with a written summary of findings and recommendations for improving the accuracy of the medical record documentation and coding.
Analyze and evaluate the effectiveness of outpatient/inpatient medical coding processes and procedures in meeting established goals.
Conduct random medical coding documentation audits for monthly Commander's Data Quality Statement and reports findings and recommendations as required.
Identify correct principal diagnosis and principal procedure from coded documents based on physician's medical record documentation and established sequencing rules and guidelines.
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