Clinical Coder-Coding

Assigns codes for diagnoses, treatments, and procedures according to the appropriate classification system for complex inpatient encounters, outpatient (OP)/emergency department (ED) or observation short stay.

Prepares and review provider documentation to determine principal diagnosis, comorbidities and complications, secondary conditions and surgical procedures and E&Ms.

Adheres to official coding guidelines when coding with accuracy and completeness as supported by documentation.

Ensures accurate coding by clarifying diagnosis and procedural information through a query process.

Assigns Present on Admission (POA) value for inpatient diagnoses.

Assigns an accurate physician name against each service and accurate time and date.

Interacts with physicians and other areas when additional coding information is needed; example to prevent medical necessity denials.

Reviews documentation to verify and when necessary, correct the patient disposition upon discharge.

Maintains the assigned target of production and accuracy of Coding.

Prioritizes work to ensure timeframe of medical record coding meets regulatory requirements.

Engages with physicians in Coding Query process and provides training as necessary.

Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines.

Prepares statistics as requested by the management.

Assists in any other relevant task that may be assigned

Manages stressful situations and handles multiple tasks at one time

Encourages a positive environment for other staff members.

Collaborates with other members of the team to carry out work smoothly