Summary
Codes and abstracts hospital medical records (including Inpatients, Observation, Outpatient Surgery, Invasive Outpatients, and Emergency Department) for diagnostic and procedural coding. Utilizes federal, state procedures/guidelines to assure accuracy of coding and abstracting and productivity standards.
Collaborates with medical staff and clinical documentation improvement (CDI) staff to clarify documentation. Maintains performance in accordance with corporate compliance requirements as it pertains to the coding and abstracting of medical records, as well as Diagnosis Related Group (DRG) assignment.
Position Responsibilities
Accurately review each record and use ICD-10-CM, ICD-10-PCS, CPT-4, and encoder to code all significant diagnoses and procedures according to AHA, AHIMA, UHDDS hospital-specific guidelines and conventions.
Code records for Inpatient, Observation, Outpatient Surgery, Invasive Outpatients, and Emergency Department, sequencing principal diagnosis and procedures per documentation and UHDDS definitions.
Use ongoing knowledge and reference material regarding DRGs to validate DRG assignments.
Apply written federal and state regulations and guidelines for definition and prioritization of abstract data elements to ensure database uniformity.
Abstract records for the same care settings, verifying or abstracting required data into the computer system according to procedures and using equipment and processes appropriately to ensure efficient coding and abstracting.
Participate in maintaining DNB and accounts receivable goals.
Maintain department-level competencies and participate in performance improvement activities.
Position Qualifications
Minimum of two years inpatient records coding experience or equivalent.
Ability to perform functions in a Microsoft Windows environment.
Detail-oriented with a high level of accuracy.
Sound decision-making skills.
Good communication and teamwork skills.
Previous experience with an electronic medical record system preferred.
Required Education
High School Diploma or GED required.
Knowledge of Anatomy & Physiology / Medical terminology required.
Training / Certifications / Licensure
Coding education preferred or equivalent experience.
AHIMA Certification: Certified Coding Specialist (CCS) required for all employees hired after 10/1/2025.
Non-CCS-Certified Hourly Rate: $26.22 - $40.65
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