Coding Specialist Certified
SUMMARY
This position is responsible for evaluating medical records and documentation, providing clinical abstracts and assigning appropriate clinical diagnosis and procedure codes in accordance with nationally recognized guidelines. Works collaboratively and supports efforts of other team members. Supports quality improvement initiatives through team participation, data collection, process change implementations, and other activities. Maintains confidentiality and protects sensitive data at all times, including patient information, proprietary information and personnel information. Adheres to organizational and department specific safety standards and guidelines.
ESSENTIAL FUNCTIONS
- Analyzes medical information from medical records and accurately codes diagnostic and procedural information in accordance with national coding guidelines and appropriate reimbursement requirement
- Provides thorough, timely and accurate assignments of ICD and/or CPT4 codes
- Assists in promoting accurate diagnostic information and complete documentation by physicians, nurses and other professionals as required
- Consults with medical providers and clinical staff to clarify missing or inadequate records and refers inconsistent patient treatment information/documentation to supervisor or individual department for clarification/additional information for accurate code assignment
- Provides Clinic with ICD, CPT and/ or HCPC changes quarterly or as needed
- Performs other duties as required and assigned
KNOWLEDGE, SKILLS AND ABILITIES
- Knowledge of anatomy, physiology and medical terminology
- Ability to code records utilizing established coding guidelines and resources
- Ability to review all PTFs to ensure all codes are current
- Ability to understand and meet coding deadlines to ensure timely submission of bills
- Ability to input abstract data and codes into computer to gather administrative and clinical data for distribution to outside regulatory agencies, third -party payers, administrative staff and physicians
- Ability to audit physician coding for errors and discrepancie
- Ability to maintain confidentiality of patient, personnel, and corporate data
- Proficiency in Microsoft Office Suite and relevant software skills
- To include position specific: e.g. HRIS, donor database, EHR, practice management systems and tools, enterprise resource planning (ERP) such as Abila, QuickBooks, etc. scheduling software, volunteer management systems, etc.
- Ability to effectively manage time with a proven ability to meet deadlines; organization and attention to detail
- Ability to operate personal computer, calculator, fax machine, copier, and other office equipment