Coding Specialist I- Inpatient Acute Care Coding

• High School Diploma or GED equivalent required and Courses in Medical Terminology, Anatomy & Physiology, ICD-CM and ICD-PCS required
• Associate's degree in coding or Bachelor's degree in coding related degree preferred;

• Experience with clinical information systems (3M grouper, electronic medical records, computer assisted coding) and coding experience

• CCS (Certified Coding Specialist) through AHIMA required within 1 year from date of hire.
• RHIT (Registered Health Information Technician) and/or RHIA (Registered Health Information Administrator) preferred

• Verbal and written communication skills.
• Basic computer skills required.

• Abstracts and ensures accuracy of diagnoses, procedure, patient demographics, and other required data elements.
• Adhere to all compliance regulations and maintains annual compliance education.
• Maintains continuing education and seeks ongoing education to improve job performance. Maintains credentials as required for job classification.
• Contacts physician when conflicting or ambiguous information appears in the medical record. Adheres to the MedStar Coding Query Policy and procedure.
• Meets established Quality standards as defined by policies.
• Meets established Productivity standards as defined by policies.
• Resolves all quality reviews timely (e.g. Medical necessity 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. Determines the sequence of diagnoses according to Uniform Hospital Discharge Data Definitions and assigns appropriate DRG (Diagnosis Related Groups).
• Exhibits knowledge of the 3M system and other work-related equipment.

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