POSITION SUMMARY Evaluates medical records, provides clinical abstracts and assigns appropriate clinical diagnosis and procedure codes in accordance with nationally recognized coding guidelines. ESSENTIAL FUNCTIONS Analyzes medical information from medical records. Accurately codes diagnostic and procedural information in accordance with national coding guidelines and appropriate reimbursement requirements. Consults with medical providers to clarify missing or inadequate record information and to determine appropriate diagnostic and procedure codes. Provides thorough, timely and accurate assignments of ICD and/or CPT4 codes, MS-DRGs, APCs, POAs and reconciliation of charges. Abstracts clinical diagnoses, procedure codes and documents other pertinent information obtained from the medical record into the electronic medical records. Seeks out missing information and creates complete records, including items such as disease and procedure codes, point of origin code, discharge disposition, date of surgery, attending physician, consulting physicians, surgeons and anesthesiologists, and appropriate signatures/authorizations. Refers inconsistent patient treatment information/documentation to coding quality analysis, supervisor or individual department for clarification/additional information for accurate code assignment. Provides quality assurance for medical records. For all assigned records and/or areas assures compliance with coding rules and regulations according to regulatory agencies for state Medicaid plans, Center for Medicare Services (CMS), Office of the Inspector General (OIG) and the Health Care Financing Administration (HCFA), as well as company and applicable professional standards. As assigned, compiles daily and monthly reports; tabulates data from medical records for research or analysis purposes. Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides all customers with an excellent service experience by consistently demonstrating our core and leader behaviors each and every day.NOTE: The essential functions are intended to describe the general content of and requirements of this position and are not intended to be an exhaustive statement of duties. Specific tasks or responsibilities will be documented as outlined by the incumbent's immediate manager.
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Job Type
Full-time
Career Level
Entry Level
Education Level
No Education Listed
Number of Employees
251-500 employees