Coder II – Health Information Management – Days – FT

Job Description

Location:

1520 Broad Ave. Gulfport,MS 39501.

Job Summary:

Performs International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) coding of all patient charts for billing, case mix, and data collection purposes. Subsequently, assigns Diagnostic Related Group (DRG) and Ambulatory Patient Classification (APC). Performs retrospective review of patient charts.

Responsibilities

• Assigns ICD and CPT codes to patient diagnoses and procedures for outpatient services
  • Assess the accuracy and completeness of all information provided in documentation
  • Assign codes for procedures, services, and diagnosis by following set classification systems
  • Identify chargeable services/items for outpatient visits and ensure that all charges are accurately billed into the system
  • Code and post procedures and accurately assign CPT and ICD codes to them
  • Prioritizes assignments according to established criteria and decrease pending accounts
  • Contacts or queries physician when additional information or clarification is needed to code
• Reviews documentation and coding for accuracy and practices compliance with coding guidelines and protocols
  • Performs compliance edits on outpatient records, and ensures discrepancies are resolved
  • Reviews abstracted and statistical data for corrections and submits findings to leader
  • Maintain current information/knowledge regarding coding principles and guidelines
  • Completes retrospective reviews on patient charts as requested
  • Assists in peer reviews on designated patient charts by utilizing established guidelines
• Utilizes the Electronic Health Record system and other related computer systems and software
  • Selects appropriate assignments for coding/abstracting from work queues
  • Enters coded and abstracted data appropriately for use within the hospital information system
  • Assigns appropriate discharge disposition to patient encounters
  • Maintains data integrity through review of the overall completeness, accuracy, and consistency of data within relevant systems

Qualifications

Required Qualifications:

Education: High School Diploma or equivalent. Anatomy and Physiology, or Medical Terminology coursework.

Licensure: CPC, COC, CPC-P, CCS, RHIT, and/or RHIA

Experience: Previous education, training and/or experience as a medical coder and/or successful completion of coder testing prior to employment.

Skills, Knowledge, Abilities: Ability to code patient records and assigns ICD, CPT, and DRG or APC accurately. Understanding of basic computer skills and computerized coding software.

Preferred Qualifications:

Education: None

Licensure: None

Experience: Previous experience as a medical records coder.

Skills, Knowledge, Abilities: Understanding of database applications and associated report writing programs.

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