BASIC FUNCTION: Reviews patient records and assigns accurate codes for each diagnosis and procedure on the accounts assigned to coder. Applies knowledge of medical terminology, disease processes, and pharmacology. Demonstrates tested data quality and integrity skills. Performs chart verification as assigned. Performs final chart reviews as necessary. SHIFT DAYS/HOURS: Remote Position Full-Time: 40 Hours per Week, Monday through Sunday. Hours and Days are Subject to change based on business necessity. ESSENTIAL FUNCTIONS: Review and abstract patient medical records. Report diagnoses, treatments, as well as surgical and non-surgical procedures for CAH facility medical services. Perform coding duties of discharged patient medical records using AHA Coding Clinic for ICD-10-CM and ICD-10-PCS, AHA Coding Clinic for HCPCS, CMS ICD-10-CM Official Guidelines for Coding and Reporting, AMA CPT Assistant, and ACEP ED Facility Level Coding Guidelines. Correctly assigns ICD-10-CM/PCS and CPT/HCPCS codes creating APG group assignments. Abide by the standards of American Health Information Management Association (AHIMA) Standards of Ethical Coding. Concerns involving compliance issues are forwarded to the Manager of HIM for action. Abide by the standards of American Health Information Management Association (AHIMA) Code of Ethics. Concerns involving compliance issues are forwarded to the Manager of HIM for action. Apply accurate charges. Queries physicians when documentation in the record is inadequate, ambiguous, or unclear for coding purposes. Report unusual findings to the supervisor when coding. Ensure code assignment is supported by provider documentation. Maintain professional competency and knowledge of third- party payer and QIO regulations. Compliant with HIPPA, demonstrates discretion and integrity. Ability to work with minimal supervision. Other duties as assigned.
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Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED