Major Responsibilities This role will have all responsibilities of coder I, II and III in addition to reviewing complex inpatient documentation at a highly skilled and proficient level to assign diagnosis and procedure codes utilizing ICD-10 CM/PCS, CPT, and HCPCS. Assigns and ensures correct code selection following Official Coding Guidelines and compliance with federal and insurance regulations utilizing an EMR and/or Computer Assisted Coding software. Adhere to organizational and internal department policies and procedures to ensure efficient work processes. Responsible for coding high dollar and long length of stay cases for all patient types. Expertise in query guidelines and coding standards. Follow up and obtain clarification of inaccurate documentation as appropriate. Serve as a subject matter expert to Coding department leaders and peers. Recommends modifications to current policies and procedures as needed to coincide with government regulations. Maintain continuing education by attending webinars, reviewing updated CPT assistant guidelines and updated coding clinics. Research coding related topics and issues. Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adhere to official coding guidelines. Practice ethical judgment in assigning and sequencing codes for proper insurance reimbursement. Collaborate with the Clinical Documentation Improvement and Quality teams to ensure a match in the DRG and reconcile each Medicare case with the working DRGs from a CDI perspective. Responsible for clinician communication related to disease processes on a clinical level to ensure accurate coding. Participate in payer audits and meetings by acting as a resource for coding-related audits, as requested. Attend meetings with clinical teams regarding updates in codes for complex specialties. Maintain the confidentiality of patient records. Report any perceived non-compliant practices to the coding leader or compliance officer. Meet and exceed departmental quality (95% or more) and productivity standards (100%). Achieve productivity expectations to support discharged not final billed (DNFB). Performs any other assigned duties as needed. Management retains the right to add or change duties at any time. Licensure, Registration, And/or Certification Required Coding Certification issued by one of the following certifying bodies: American Academy of Coders (AAPC) or American Health Information Management Association (AHIMA) Education Required Associate's Degree in Health Information Management or related field. Experience Required Typically requires 7 years' experience inpatient coding in an acute care tertiary facility that includes experience in revenue cycle processes, Clinical Documentation Improvement, Research and health information workflows. Knowledge, Skills & Abilities Required Advanced proficiency of ICD, CPT and HCPCS coding guidelines. Advanced knowledge of medical terminology, anatomy and physiology. Excellent computer skills including the use of Microsoft Office products and electronic mail, with exposure or experience with electronic coding systems or applications. Excellent communication (oral and written) and interpersonal skills. Excellent organization, prioritization, and reading comprehension skills. Excellent analytical skills with a high attention to detail. Ability to work independently and exercise independent judgment and decision making. Ability to meet deadlines while working in a fast-paced environment. Ability to take initiative and work collaboratively with others. Physical Requirements And Working Conditions Exposed to a normal office environment. Must be able to sit for extended periods of time. Must be able to continuously concentrate. Position may require travel to other sites; may be exposed to road and weather hazards. Operates all equipment necessary to perform the job. This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties. #J-18808-Ljbffr