Job Description

RESPONSIBILITIES

• Assigns codes for diagnoses, treatments, and procedures according to the appropriate classification system for complex inpatient encounters, outpatient (OP)/emergency department (ED) or observation short stay.
• Prepares and review provider documentation to determine principal diagnosis, comorbidities and complications, secondary conditions and surgical procedures and E&Ms.
• Adheres to official coding guidelines when coding with accuracy and completeness as supported by documentation.
• Ensures accurate coding by clarifying diagnosis and procedural information through a query process.
• Assigns Present on Admission (POA) value for inpatient diagnoses.
• Assigns an accurate physician name against each service and accurate time and date.
• Interacts with physicians and other areas when additional coding information is needed; example to prevent medical necessity denials.
• Reviews documentation to verify and when necessary, correct the patient disposition upon discharge.
• Maintains the assigned target of production and accuracy of Coding.
• Prioritizes work to ensure timeframe of medical record coding meets regulatory requirements.
• Engages with physicians in Coding Query process and provides training as necessary.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines.
• Prepares statistics as requested by the management.
• Assists in any other relevant task that may be assigned
• Manages stressful situations and handles multiple tasks at one time
• Encourages a positive environment for other staff members.
• Collaborates with other members of the team to carry out work smoothly

Accountabilities

• Ensures that codes are assigned correctly and sequenced appropriately as per government and insurance regulation
• Implements strategic procedures and choosing strategies and evaluation methods that provide correct results

QUALIFICATIONS

Experience :-

Required:

• 2-4 years of relevant progressive experience in a similar role
  

Desired:

• Experience in a large healthcare facility

Educational Qualification: Required:

• Bachelor Degree in Health Information Management or relevant field with or Diploma with 3 years of additional experience in Healthcare

Desired:

• Master degree or equivalent in Health Information Management or relevant field