This role is responsible for abstracting, coding, sequencing, and interpreting clinical information from various medical records including inpatient, outpatient, emergency department, pro fee, and clinical records. The position requires the assignment of correct principal diagnoses, secondary diagnoses, principal procedure, and secondary procedure codes with accurate sequencing. The Coder Physician will utilize technical coding principles and DRG/APC reimbursement expertise to assign appropriate codes, abstracting and coding pertinent medical data into multiple software programs and/or encoders, and following official coding guidelines to review and analyze health records. Maintaining compliance with external regulatory and accreditation requirements, as well as State and Federal regulations, is crucial. The role involves extracting pertinent data from patient health records to determine appropriate coding for reports and billing documents, identifying codes for reporting medical services and procedures performed by physicians, and entering these codes into various computer systems. Productivity tracking and maintenance of a 95% quality rating are key performance indicators. Duties must be performed in compliance with Company policies and procedures, including those related to HIPAA and compliance.
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Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree