Job Description Summary This position performs facility coding and abstracting functions of Inpatient. Responsibilities and Duties Assign appropriate admit, principal, and secondary diagnoses and/or procedure codes by reading documentation present in the medical record and applying knowledge of correct coding guidelines as appropriate for hospital service and/or patient type while maintaining 95% quality and meeting minimum Coder productivity requirements. Assign Present on Admission POA indicators to all inpatient account diagnoses as required by official coding guidelines. Accurately assign DRG/MSDRG/APR-DRG at the minimum standards of 95% . Review diagnosis and CC/MCC for maximum severity of illness/room of service. Clinical understanding of laboratory and radiology values. Knowledge of quality outcomes indicators and work with CDS to improve physician documentation and case mix index. Assign Principal Diagnosis accurately at least 95% or better. Monitor and appropriately assign HAC codes when appropriate. Recognize when it is necessary to obtain further clarification from a physician when documentation is inadequate, ambiguous, or unclear for coding purposes. Assist educators and supervisors with reviewing accounts denied by RAC and other governmental payers for appropriate documentation to support original coding. In the event of insufficient, missing or conflicting documentation, assign transaction codes in HBOC system and follow department policy for follow up and physician query. Abstract all data elements necessary to complete UB0 4 and meet hospital-reporting requirements. Verify demographics, correct account number, charges and service and identify missing or incorrect forms in each record. Identify problem cases on the DNFB and forward to appropriate staff for follow up. Other duties are assigned by supervisor as needed. The role focuses on safety, quality, and efficiency. Minimum Qualifications High School or GED in Health Information Management (Required). AHIMA – American Health Information Management Association: Certified Coding Specialist (CCS). Work Details Work Shift: Day Scheduled Weekly Hours: 40 Department: Hospital Coding Equal Employment Opportunity OhioHealth is an equal opportunity employer and fully supports and maintains compliance with all state, federal, and local regulations. OhioHealth does not discriminate against associates or applicants because of race, color, genetic information, religion, sex, sexual orientation, gender identity or expression, age, ancestry, national origin, veteran status, military status, pregnancy, disability, marital status, familial status, or other characteristics protected by law. Equal employment is extended to all persons in all aspects of the associate-employer relationship including recruitment, hiring, training, promotion, transfer, compensation, discipline, reduction in staff, termination, assignment of benefits, and any other term or condition of employment. Remote Work Disclaimer Positions marked as remote are only eligible for work from Ohio. #J-18808-Ljbffr