20/03/2021
We are
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• Responsible for reviewing patient records and codifying results for reimbursement or payment purposes.
• Responsible for abstracting, coding, and sequencing the classification of medical and surgical procedures, diagnosis,
and treatment modalities on Inpatient and Outpatient encounters.
• Review appropriate provider documentation to determine the principal diagnosis, co-morbidities, and complications,
secondary conditions, and significant procedures.
• Select the latest, most accurate, and descriptive codes from the listings of International Classification of Diseases,
Tenth Revision, Clinical Modification (ICD-10 CM/PCS), Current Procedural Terminology (CPT) coding system, and
Healthcare Common Procedure Coding System (HCPCS).
• Utilize available resources and coding guidelines to identify accurate codes and research regulations to ensure
accuracy of coding documentation.
• Assign Present on Admission (POA) value for inpatient diagnoses as a supplement for ICD-10 CM coding.
• Assign correct diagnostic related grouping (DRG) and perform coding compliance reviews. Follow official coding
guidelines to review and analyze health records.
• Enter codes into the computer system, extract the required information from source documentation and enter data into
encoder and abstracting system.
• Investigate edits, recognize issues, make the necessary corrections and release bills for payment.
• Abide by the Standards of Ethical Coding, set forth by the American Health Information Management Association
(AHIMA), adhere to official coding guidelines, and maintain current knowledge of the information contained in the
Coding Clinic, CPT Assistant, and the Official Guidelines for Coding and Reporting.
• Maintain strict confidentiality of all data records.
• Knowledge, understanding, and compliance with all applicable Federal and Local laws and regulations relating to job
duties.
• Knowledge, understanding, and compliance with HCCA HC policies and procedures.
• Provide feedback to management concerning possible problems or areas of improvement.
• Make recommendations to implement improved processes
Work and Time Requirements
• Regular and reliable attendance is an essential function of the position.
• Flexibility to work 8 hours or extended shift dependent on client need.
Qualifications and Educational Requirements
• Graduate of Bachelor of Science in Nursing
• Current PRC license
• Knowledgeable in anatomy, medical terminology, pharmacology, and disease process
• Excellent reading comprehension and analytical skill
• Excellent verbal and written communications skills
• Graduated with honors (cum laude, etc.) preferred
• With or without clinical/hospital experience
• With or without BPO/CPO work experience
• AHIMA or AAPC medical coding certification
• No less than 6 months of medical coding experience
