Role Description
The HIM Coding Specialist is responsible for coding accurately, diagnoses and procedures utilizing the International Classification of Diseases, Clinical Modification (ICD-9/10-CM) and/or the Current Procedural Terminology (CPT) coding systems. Assigns ICD-9/10-CM codes in the proper sequence to reach the appropriate DRG.
Qualifications
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Completion of required course work and/or degree for accreditation or registration with the American Health Information Management Association (AHIMA).
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Required credentials include accreditation as a Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist (CCS), or Certified Coding Associate (CCA) with AHIMA.
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A recent Health Information Management (HIM) or Health Information Technology (HIT) graduate is preferred if accreditation is successfully completed within 6 months of employment.
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Membership in Clinical Coding Society (a division of AHIMA) is preferred.
Requirements
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Stand and/or walk frequently.
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Sit frequently.
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No lift and/or carry.
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No push and/or pull.
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Visual acuity and manual dexterity within normal limits.
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Bend, stoop, and crouch occasionally.
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Reach floor to overhead occasionally.
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Computer use frequently.
Essential Functions
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Demonstrates competency in Medical Record Abstract, Medical Record Control, Medical Record Index, and DRG/Case Mix applications in Affinity system.
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Abstracts and verifies information such as service codes, time of discharge, surgical data, transferring status, observation times, and physician relationship from the medical record.
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Demonstrates competencies established by Department Director/Coding DRG Coordinator.
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Assigns diagnostic and operative/procedure codes for inpatient and outpatient records, utilizing ICD-9/10-CM.
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Reviews each medical record to be coded, ensuring sufficient documentation to support the ICD-9/10-CM or CPT-4 codes assigned.
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Demonstrates ability to reorganize work to satisfy fluctuations in volume and staffing adjustments.
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Reviews APC edits on outpatient accounts and adds modifiers when necessary to produce clean billing claims.
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Provides coding assistance to Home Health in the absence or direction of the Coding/DRG Coordinator.
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Participates in audits of medical records for coding accuracy.
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Performs other duties as assigned by Coding/DRG Coordinator or HIM Director.
Benefits
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Supportive environment where collaboration is key.
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Every voice is valued.
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Opportunities for continuing education and professional growth.