Summary: Under the general supervision of the Coding Manager and according to established procedures, accountable for assignment of diagnoses and procedures using ICD10 CM/PCS and CPT Codes. Requires knowledge of all aspects of hospital coding and strong understanding of coding guidelines. Abstracts required data into hospital information system. Ensure records are coded in an accurate and timely manner. Interprets a wide variety of clinical and diagnostic documentation, including complex medical treatment to identify diagnoses, complications, comorbidities and procedures associated with inpatient care.

Education: In addition to the skills normally obtained through completion of a High School education, a Bachelor or Associates Degree is with RHIT, RHIA, preferred.

Licensure: Certified Coding Specialist (CCS) is required.

Experience: Three years of experience as a hospital coder. Basic computer knowledge. Meditech experience helpful, 3M experience preferred. Extensive knowledge and experience in coding and abstracting clinical information from inpatient medical records. Must be a self-starter and have the ability to work in a deadline oriented environment. Working knowledge of computerized abstracting systems and automated encoding systems. Strong knowledge of medical terminology, anatomy and physiology. Proficient in utilizing multiple payer specific DRG groupers. Through knowledge of latest versions of DRG, ICD 10 and CPT coding systems. Proficient with Microsoft applications, encoder, Meditech preferred.

Working Conditions, Physical Environment and/or Safety Requirements: Office or suitable home-office environment. Requires long periods of visually examining documents and viewing computer screens. Monday – Friday but could include weekends/holidays if deemed necessary. Option to perform coding remotely, with the signing of a telecommuting agreement.

Interrelationships: Business office, Medical staff, Registration, Mobile Care, Laboratory, Radiology, Case