REQUIREMENTS:

License/Certification: Must possess one of the following AAPC/AHIMA certifications: Certified Inpatient Coder (CIC), Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA)
Experience: Minimum of 1-2 years’ experience as an Inpatient Coder at an acute care or academic teaching facility required or successful completion of Inpatient Coding apprenticeship program.
Proficiencies: Extensive knowledge of medical terminology, anatomy and physiology, pathophysiology, pathology and laboratory medicine, coding guidelines for ICD-10, CM, PCS, CPT, Modifiers, etc.
Knowledge of legal, regulatory, and policy compliance issues related to medical coding and billing procedures, and documentation including CMS guidelines.
Proficient computer skills using MS-Word, Excel, PowerPoint, Outlook, Electronic Medical Records (EMR) systems including Paragon, eClinical Works, Computer Assisted Coding (CAC)

RESPONSIBILITIES:

Reviews medical records to identify diagnoses, CPT procedures and PCS procedures relative to the patient’s encounter.
Selects the principal diagnosis and principal procedure, along with other diagnoses and procedures using UHDDS definition. Ensures appropriate DRG assignment.
Abstracts appropriate information from the medical record based on the guidelines provided by the hospital and after a thorough review of the medical record.
Solicits clarification from the physician regarding ambiguous or conflicting documentation in the medical record using guidelines provided by the hospital.
Ensure all coding complies with the ethical coding standards/guidelines and regulatory requirements.

Apprenticeship,