Coding Specialist Certified

Coding Specialist Certified

The responsibility of the Coding Specialist Certified is to search a patient's entire medical record to ensure comprehensive coding and abstracting utilizing the coding rules, principles and ethics under the supervision of the Coding Supervisor and Manager, Health Information Management. With quality and reimbursement contingent upon coding, it is the responsibility of the Medical Center Coding Specialist Certified to have knowledge of DRG methodology, ICD-10, CPT-4 and APC coding rules and principles.

Minimum requirements include:

Education:

1. Graduate of an approved Health Information Management Technology program, preferred.
2. Must have Registered Health Information Technician (RHIT) credentials, Certified Coding Specialist (CCS) or other relevant credentials such as Certified Professional Coder (CPC) or one year of relevant experience.
3. If does not have credentials, must obtain the required credentials within 1 year of hire/transfer.
4. OR
5. Graduate of Medical Office Specialist program with current, acute care experience with ICD-10, CPT, DRG coding rules and methodologies required.
6. Must have Certified Coding Specialist (CCS) or other relevant credential or one year of relevant experience.
7. If does not have credentials, must obtain the required credentials within 1 year of hire/transfer.

Experience:

1. Current, acute care experience with ICD-10, CPT, DRG, APC coding rules and methodologies preferred.

Knowledge, Skills, Abilities:

1. Demonstrates knowledge of diagnostic and procedural terminology, medical terminology and disease processes (anatomy and physiology).
2. Self-motivated individual with personal integrity to organize work and work independently.
3. Typing skills with basic knowledge of computer operations.
4. Communication skills necessary to approach the medical staff, hospital personnel, ancillary department etc. for any clarifications regarding record questions or problems utilizing coding rules and principles.

License/Certification/Registration:

1. Registered Health Information Technician (RHIT) and/or Certified Coding Specialist (CCS) and/or Certified Professional Coder (CPC) are required within 1 year of hire/transfer.

Supervision received:

Receives minimal supervision from the Supervisor, HIM Coding. Must be able to work independently.

Supervision given:

None

Responsibilities

Essential functions include:

1. Reviews the medical record for diagnoses and procedures performed.
2. Identifies and sequences principal diagnosis, secondary diagnoses, principal procedures, complications and comorbid conditions, for optimal reimbursement, utilizing proper coding practices, on a daily basis.
3. Selects ICD 10-, CPT-4, DRG code assignments.
4. Performs duties involving abstracting information from the medical record and entering the information into the in-house computer systems and interfaces.
5. Meets Performance Standards for Insurance Billing.
6. Processes incomplete records.
7. Maintains timely completion of records.
8. Remains current in coding rules and practices.
9. Participates as a team member to the organization.
10. Practices excellent communication skills.

Non-essential functions include:

1. Performs related and miscellaneous duties as assigned.