Analyzes, sequences and validates assigned codes based on medical record documentation using the automated encoder, book and coding compliance resources. Demonstrates complete understanding of coding rules, anatomy, physiology and medical terminology to appropriately code patient information. Reviews all medical record documentation to determine and assign diagnoses, procedures, level codes and modifiers. Ensures that coding compliance, regulatory and reimbursement requirements are met through the process of assigning reimbursement classifications. Abstracts and enters demographic, clinical and related patient information into the computer system. Assesses adequacy of documentation and queries physicians and other healthcare providers to obtain additional medical record documentation or to clarify documentation to ensure accurate and appropriate coding and grouping. Reconciles, identifies and retrieves medical records to be coded. Maintains a 95% ongoing accuracy rate. Consistently achieves daily coding output within the minimal productivity standards set by MACC. Self-manages and prioritizes work flow to achieve timely submission of claims and optimal productivity. Maintains accurate productivity logs and provides this information to management in a timely fashion. Assists in the orientation and development of new coding personnel. Assumes professional responsibility for development of skills and ongoing education to maintain Active Coding certification. Remains abreast of developments in health information management by pursuing a program of professional development, attending educational programs and meetings and reviewing pertinent literature. Continuously monitors medical record documentation, individual performance and department workflow as related to the coding function to identify problems and potential solutions (especially related to errors and compliance issues). Communicates with the PB Coding Manager to find solutions and implement changes to increase productivity and department efficiency. Performs all duties and interacts with others in a professional manner. Performs other related duties as assigned.
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Job Type
Part-time
Career Level
Mid Level
Education Level
High school or GED