Job Posting for Coding Spec I Outpt at MedStar Health
Codes and abstracts primarily Emergency Department and other outpatient records using ICD-10-CM, andother applicable patient classification schemes. May also perform beginning level of AmbulatorySurgery
High school graduation or equivalent required. Associates or Bachelors in coding related degree preferred. Coding courses in ICD-10-CM and CPT-4 preferred.
Coding experience preferred. Experience with clinical information systems (3M grouper, Softmed, electronic medicalrecords, computer assisted coding)preferred.
CPC (Certified Professional Coder), CCA (Certified Coding Associate) or other coding certification credentials are required within 1 year from date of hire. RHIT (Registered Health Information Technician) and RHIA (Registered Health Information Administrator) preferred.
Knowledge, Skills & Abilities
Verbal and written communication skills. Basic computer skills required. 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 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.
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 standards as defined by policies.
Meets established productivity standards as defined by policies.
Exhibits knowledge of the 3M system and other work-related equipment.
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.
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, procedural codes, and appropriate modifiers using standard guidelines and automated encoding software maintaining departmental accuracy standards.