CODER I (on-site)

Job Description

Job Description

Job Title: Coder I

Home Department: HIM

Reports To: HIM Director

Direct Reports: None

FLSA Classification: Non-Exempt

Position Summary

The Coder I is responsible for conversion of diagnoses and treatment procedures into codes using an international classification of diseases. Requires skill in the sequencing of diagnoses/procedures to optimize reimbursement and compliance to documentation and medical policy guidelines for all payers.. Ensures that records are coded in an accurate and timely manner.

General Duties, Tasks and Responsibilities

• Ensures that records are coded accurately and timely; reviews patient charges for inconsistencies; contacts physician if diagnosis is not available on chart; refers charts accordingly.
• Utilizes computerized coding/abstracting equipment, coding software, coding references and resources, transcription equipment, and medical dictionaries to ensure the most accurate and efficient entry of information.
• Codes all diagnoses/procedures in accordance to ICD-10-CM/PCS coding principles and the Coding Manual; ensures data quality and optimum reimbursement allowable under the federal and state payment systems are obtained.
• Consistently meets or exceeds department productivity standards for daily work assignments.
• Meets or exceeds department quality standards for selecting principal diagnoses and procedures appropriately and/or correctly and coding accordingly.
• Maintains the number of DRG/coding changes below department standards on a quarterly basis per PRO threshold.
• Understands medical/legal implications of incorrect coding and the responsibility of the certified coder to ensure coding accuracy.
• Complies with all established safety procedures to ensure a safe environment for patients, visitors and staff.
• Participates in performance improvement activities.
• Performs other duties as assigned.

Education Requirements

• Associate's Degree in related field / Equivalent combination of education and experience required

Certification/Licensure Requirements

• CCA, CCS, RHIA, RHIT Certification required within 18 months of hire

Experience Requirements

• Hospital Medical Coding minimum 3 years Preferred

Computer Skills

• Strong computer skills including Microsoft Word, Excel and Outlook

Additional Skills

• Ability to work independently, prioritize and complete tasks in a timely manner
• Knowledge of diagnoses/procedures in accordance with ICD-10-CM/PCS coding principles
• Knowledge of medical terminology, anatomy and physiology