Reviews moderate to high complexity medical records to identify the appropriate principal diagnosis and procedure codes and all other appropriate secondary diagnoses and procedure codes and assign Present on Admission indicators, Hospital Acquired Conditions and Core Measures for all diagnosis codes. Facilitates appropriate MSDRG for inpatient medical records and appropriate APC assignment for outpatient medical records using UHDDS and other facility guidelines. Reviews charges and Evaluation and Management levels. Demonstrates the technical competence to use the facility encoder as it interfaces with the hospital mainframe and/or EMR in an on-site or remote setting. Abstracts coded data and other pertinent fields in the hospital electronic health record. Ensures the accuracy of data input. Meets established quality and productivity standards. Stay abreast of coding principles and regulatory guidelines related to inpatient and/or outpatient coding.
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Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED