What are the responsibilities and job description for the Coder, Certified Inpatient position at Shore Medical Center?
Position Summary
The Certified Inpatient Coder is responsible for the accurate diagnostic and procedural coding of medical records. The Coder is also responsible for the accurate abstracting of medical, financial and demographic information, in addition to performing other events.
Core Duties and Responsibilities
• Per standard process reviews and evaluates designated medical records to identify diagnoses and procedures and accurately assigns and sequences ICD CM, ICD PCS and/or CPT codes
• Reviews medical record for proper assignment of diagnosis and procedure codes according to AHA coding guidelines
• Contacts Physicians and Other Healthcare Providers to clarify diagnoses and procedures
• Sequence codes appropriately for accurate DRG
• Abstracts required data from the medical record, including, but not limited to, Attending Physician, Discharge Disposition, ICD-9-CM , ICD-10-CM, CPT diagnosis and/or procedure codes, and Physician Consultation
• Completes medical record abstracts
• Verifies patient demographic data for accuracy and completeness by comparing data in computer system with the medical record
• Reviews the accuracy and consistency of medical record documentation and brings any inconsistencies to the attention of the appropriate individual
• Keeps up to date on coding and regulatory changes. Maintains individual abstracting and review manual
• Achieves a "Meets Expectations" rating on coding /DRG audits
• Meets productivity standards for coding
Minimum Requirements
• Certified Coding Specialist or eligible
• RHIT or RHIA
• 3 years experience as a medical coder in an acute care hospital setting
• Knowledge and understanding of healthcare reimbursement methodologies and billing procedures
• Knowledge of health information management functions and computer operations
• Complete understanding of current coding system and guidelines (both ICD 10 CM and PCS)
Additional information
• To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill, and/or ability required.
• This job description should not be construed as an exhaustive statement of duties, responsibilities or requirements, but a general description of the job. Nothing contained herein restricts the company’s rights to assign or reassign duties and responsibilities to this job at any time.
• Shore Medical Center is an Equal Opportunity Employer. All applicants will receive consideration for employment without regard to sex, affectional or sexual orientation, gender, gender identity, orientation or expression; marital status, domestic partnership status, civil union status, pregnancy, race, creed, ancestry, color, ethnicity, national origin, age, disability, religion, genetic information, or veteran status or any other basis prohibited by law.
