<ul> <li> <p>JOB SUMMARY</p> </li><li> <p>Reviews patient records, assigns diagnostic and procedural codes, performs related functions and participates in Performance Improvement activities.</p> </li><li> <p>ESSENTIAL FUNCTIONS</p> </li><li> <p>Diagnostic Coding of All Medical Records Reported on patient Bills</p> </li><li> <p>By coding all diagnoses, treatments, and procedures according to the appropriate classification system for the category of patient encounter</p> </li><li> <p>By accurately coding all inpatient records in accordance with ICD-10 CM/PCS coding rules and guidelines in a timely manner with a 95% accuracy rate</p> </li><li> <p>By following approved coding conventions, assigns diagnostic and procedural codes to inpatient records.</p> </li><li> <p>Reviews AHA Coding Clinic and demonstrates the ability to accurately apply new coding guidelines.</p> </li><li> <p>Research new diagnostic and procedure codes as required to perform the coding function.</p> </li><li> <p>Informs coding supervisor of trends and opportunities for improvement in clinical documentation.</p> </li><li> <p>Works collaboratively with other coders.</p> </li><li> <p>Adheres to the American Health Information Management's Code of Ethics.</p> </li><li> <p>Locates Medical Records That Require Code Assignment</p> </li><li> <p>By searching master patient index; identifying the location of existing patient records and obtaining the documentation required for code assignment.</p> </li><li> <p>Maintains Medical Records Operations</p> </li><li> <p>By following policies and procedures; reporting needed change</p> </li><li> <p>Resolves Medical Record Discrepancies</p> </li><li> <p>By acting as a resource to other staff on coding issues</p> </li><li> <p>By assisting the physicians with documentation improvement via the diagnostic query form</p> </li><li> <p>By collecting and analyzing information</p> </li><li> <p>Maintains Historical Reference</p> </li><li> <p>By abstraction and data entry of all inpatient records into the Good Shepherd Hospital computer system for clinical and financial purposes</p> </li><li> <p>By abstracting and coding clinical data, such as diseases and procedures, using standard classification systems.</p> </li><li> <p>By providing DRG/CMG forecasting information to Nurse Liaison as needed.</p> </li><li> <p>By accurately assigning the correct principal diagnosis on LTCH and rehab accounts.</p> </li><li> <p>By performing weekly/bi-weekly concurrent chart reviews for any potential DRG/CMG changes during the patient's stay.</p> </li><li> <p>By coding all discharged charts timely and accurately</p> </li><li> <p>Provides Medical Record Information</p> </li><li> <p>By providing codes for billing and answers questions from hospital staff</p> </li><li> <p>By assisting physicians and other direct patient care professionals in questions regarding level of detail for diagnostic entries, according to the organization's guidelines.</p> </li><li> <p>Maintains the Stability and Reputation of the Hospital</p> </li><li> <p>By complying with legal requirements.</p> </li><li> <p>QUALIFICATIONS:</p> </li><li> <p>To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.</p> </li><li> <p>Education</p> </li><li> <p>High School Diploma required</p> </li><li> <p>Completion of the AHIMA independent study program preferred</p> </li><li> <p>Work Experience</p> </li><li> <p>2-4 years of inpatient coding experience utilizing ICD-9-CM and/or ICD-10-CM/PCS required</p> </li><li> <p>Licenses / Certifications</p> </li><li> <p>RHIA, RHIT, CCS, CPC, active member in AHIMA preferred</p> </li></ul>