Job Description

Coder, 40 HRs/Week, 8AM-4:30PM

In accordance with ICD-10-CM, CPT and HCPCS Official Rules for Coding and Reporting, American Hospital Association (AHA) Coding Clinic, AHA Coding Clinic for HCPCS, American Medical Association (AMA)CPT Assistant , American Health Information Association (AHIMA) "Guidelines for Achieving a Compliant Query", Federal and State Regulations, National Correct Coding Initiative and facility based coding policies and procedures, assigns diagnostic and procedural codes to medical records based on the source documentation within the medical record. Abides by Standards of Ethical Coding as set forth by American Health Information Association (AHIMA).


ò Responsible for assigning diagnostic and procedural codes to patient records in adherence to ICD-10-CM and CPT/HCPCS codes or other designated coding classification system based on source documentation within the patient record
ò Reviews medical records for the determination of accurate assignment of all documented diagnoses and procedures
ò Reviews medical records for data abstracting of specified data elements
ò Assigns and sequence codes accurately based on patient record documentation
ò Assign the appropriate discharge disposition based on patient records documentation
ò Assign the appropriate Present On Admission (POA) indicator and Hospital Acquired conditions (HAC) based on medical record documentation
ò Abstract and enter coded data hospital statistical and reporting requirements
ò Communicate documentation improvement opportunities and coding issues to appropriate personnel for follow-up and resolution
ò Use coding resources as tools to ensure coding compliance
ò Meets coding and abstracting quality and productivity standards
ò Track and maintain continuing education credits to maintain professional credentials
ò Communicate with co-workers, management and hospital staff regarding clinical and reimbursement issues
ò Performs all job functions in compliance with federal, state and local laws, and hospital policies and procedures
ò Conduct chart reviews based on third-party audits or based patient complaints received from the system financial services
ò In keeping with the AHIMA "Guidelines for Achieving A Compliant Query", and hospital policies and procedures query the medical staff when additional documentation clarification is required to achieve optimal coding
ò Performs other duties as required by the position


Science or Associate Degree in Health Information Management or Coding Certificate from an accredited program by American Health Information Management (AHIMA) or American Association of Coding Professionals (AAPC) required.
Credentials to include one of or a combination of the following: Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), and/or Certified Coding Specialist (CCS) or CCS eligible, or Certified Professional Coder (CPC)
ICD-10-CM training and proficiency required
Experience with various coding and abstracting applications, e.g. 3M
Ability to maintain a minimum of 95% coding quality accuracy while achieving the hospital productivity standards
Position requires maintaining confidentiality according to hospital policies and procedures

Application Instructions

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