Role Description - Abstracts data in compliance with national, regional, and local policies, and interprets and reviews medical record documentation to assign accurate ICD-10 diagnosis and CPT procedure codes. - Utilizes practice management system (PMS) to accurately account for demographics and services performed for all scheduled and unscheduled surgical cases according to standard procedures and coding guidelines. - Utilizes individual hospital medical record systems and coordinates with physicians and staff to obtain clinical documents and demographics required for appropriate coding and billing for all hospital procedures. - Provides education and support to clinical areas regarding appropriate documentation and coding of services to achieve accurate billing. Maintains effective communication with providers concerning coding issues. Qualifications - High school diploma/GED or equivalent working knowledge preferred. - Accredited by the American Health Information Management Association (CCS-P) or the American Academy of Professional Coders (CPC). Requirements - A minimum of one of the following credentials: CCS-P or CPC. - Meets established coding and abstracting quality and productivity standards. - Experience with various coding software. Previous experience with remote coding is preferred. - Possesses PC skills, both keyboarding and applications. - Requires a good understanding of anatomy, physiology, medical terminology, and disease processes. - Ability to work independently. - Excellent attention to detail.

• Conducting coding audits prior to payment release. • Performing post-payment coding reviews with overpayments. • Sending coding education correspondence to applicable providers. • Reviewing medical records, patient medical history and physical exams. • Assisting with validation audits to evaluate medical record documentation. • Interpreting medical documentation to ensure coding captures HCC conditions. • Developing tools and metrics to improve coding and documentation accuracy. • Providing high level of customer service to internal and external clients. • Escalating appropriate coding audit issues to management. • Participating in and supporting ad-hoc coding audits as needed. • Supporting ongoing programs to minimize organizational risk in RADV Audits. • Completing assigned coding projects. • Other duties as assigned.

• The Medical Coder 3 (inpatient and ambulatory surgery) abstracts clinical information from a variety of medical records, charts and documents and assigns appropriate ICD-10 - CM/PCS and CPT codes to patient records according to established procedures. • Works with coding databases and confirms DRG assignments. • Familiar with standard concepts, practices, and procedures within a particular field. • Relies on instructions and pre-established guidelines to perform the functions of the job. • This position relies on guidelines and some experience and judgment to complete job and works under general supervision.

• Analyzes relevant clinical and demographic information from the Health Information record • Assigns appropriate ICD-10 and CPT codes following appropriate guidelines • Ensures compliance with CMS, state and other regulatory agencies • Provides mentorship and training to on-boarding coders • Completes analysis of documentation, abstracting and code assignment by body system, organ, etiology and morphology • Performs queries and obtains documentation required for coding for records maintained in other departments • Coordinates documentation needs, query follow-up and final DRG assignment with the Clinical Documentation Specialist • Reviews provider documentation for coding appropriateness • Analyzes medical records to complete accurate code selection • Assigns diagnosis and procedure codes for clinic visits, surgical procedures/deliveries, and other billable professional services • Acts as a mentor to other team members