High school graduation or equivalent; coding courses in ICD-10-CM and CPT-4 required.
2 years coding experience required. Experience with clinical information systems (3Mgrouper; Softmed; electronic medical records; computer assisted coding).
CCS (Certified Coding Specialist) for Inpatient, and CCS or CCS-P (Certified CodingSpecialist - Physician-based) for Ambulatory Surgery required. Certification as a Registered HealthInformation Technician (RHIT), Registered Health Information Administrator (RHIA) preferred.
Knowledge, Skills & Abilities
Verbal and written communication skills. Basic computer skills preferred. Knowledge of medicalterminology, anatomy, physiology.
Primary Duties and Responsibilities
Abstracts and ensures accuracy of diagnosis, procedure, patient demographics, and other required data elements.
Adheres to all compliance regulations and maintains annual compliance education. Maintains continuing education. Maintains credentials as required for job classification.
Contacts physician when conflicting or ambiguous information appears in the medical record.
Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.
Meets established Quality, Accuracy, and Productivity standards as defined by policies.
Participates in meetings and on committees and represents the department and hospital in community outreach efforts.
Participates in multi-disciplinary quality and service improvement teams.
Performs other duties as assigned.
Resolves all quality reviews timely (e.g. LMRP reviews; Coding Quality assurance reviews; external vendor reviews).
Reviews medical record documentation to identify diagnoses and procedures. Assigns correct diagnostic and procedural codes using standard guidelines and automated encoding software maintaining departmental accuracy standards.
About MedStar Health
MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation and research. Our 30,000 associates and 5,400 affiliated physicians work in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest visiting nurse association in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar is dedicated not only to teaching the next generation of doctors, but also to the continuing education and professional development of our whole team. MedStar Health offers diverse opportunities for career advancement and personal fulfillment.