Overview
Codes diagnoses and procedures of patient records and abstracting information at defined facilities for reimbursement, research, and to generate statistical data. Performs other duties as assigned.
Job Responsibilities
Codes diagnoses and procedures of records pertaining to inpatient records.
Abstracts information by reviewing records for reimbursement, statistical purposes for the daily operations, medical staff, and regulatory agencies.
Serves as a resource to physicians, physician office staff, clinical documentation specialists, case managers, etc.
Completes assigned goals.
Education
Skill in communicating clearly and effectively using standard English in written, oral and verbal format to achieve high productivity and efficiency. Skill to write legibly and record information accurately as necessary to perform job duties.
Experience
Skill and proficiency in coding inpatient records at defined Tier 1 hospitals utilizing ICD CM and CPT through a minimum of 3 years' experience in an acute care facility; 5 years preferred.
Training
Minimum: ICD-CM Diagnosis and Procedure Coding.
Preferred: CPT Coding.
Licensure Description
One of the following: Certified Coding Specialist (CCS), Registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT).
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