Specialist Clinical Coding II

Reviews inpatient or observation, same day surgery, and interventional procedure records or emergency department or complex ancillary records. Identifies and codes principal and secondary diagnoses and principal and secondary procedures in appropriate sequence so that the accurate DRG/APC will be assigned according to Official Coding Guidelines to provide information for billing purposes. Meets department coding standards for quality and productivity of 96%. (New staff are expected to meet these standards upon completion of the training period).

Assigns all codes based on documentation. Participates in corporate compliance program. Upholds the highest ethical standards.

Abstracts demographic and medical information into computer system following departmental guidelines to provide an accurate data base for statistical reference.

Communicates with Corporate Coding Manager, Coding Team Leader, CDI Specialists, Patient Accounts staff and fellow coders in a professional manner as needed regarding held accounts, coding changes, coding questions, physician queries, rebills, etc.

Completes various reports such as productivity reports, statistical reports and log sheets in order to maintain an accurate source of reference material and other documentation. Performs daily or weekly follow-up of all dates assigned and submits updates accordingly.

Attends educational programs and applies knowledge to enhance job performance. Uses resources available for accurate coding (i.e., Coding Clinic and CPT Assistant).

Performs other duties as assigned.

Education, Credentials, Licenses:

• Associate or Bachelors degree (or equivalent hospital based coding experience)

• CCS, CPC-H, RHIT, or RHIA credentials

• Physician coding credentials of CCS-P and CPC are not preferred but recognized for coding other than inpatient.

• An apprentice credential is not sufficient.

Specialized Knowledge:

Medical Terminology, Anatomy and Physiology

ICD/CPT experience Prospective Payment Systems, Outpatient Medical Necessity.

Use of personal computer

Kind and Length of Experience:

Two to Four years hospital coding experience

DESIRABLE

Encoder experience; Clinical Documentation experience; CAC (Computer Assisted Coding) experience.

FLSA Status:

Non-Exempt

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