Job Summary: Under limited supervision, codes and abstracts patient records using the appropriate coding/abstracting system. Communicates with Medical Staff and hospital staff to improve the documentation to support the coding process. Essential Functions: Consistently uses an outward mindset and puts forth exemplary effort in accomplishing his/her goals and objectives in a manner that helps others to achieve their goals and objectives. Code outpatient (for example day surgery, observation, emergency room, outpatient service, diagnostic) records using the appropriate coding system for diagnoses (ICD-10) and procedures (CPT & PCS) Maintain coding quality as evidence by coding accuracy rate. Uses the appropriate encoder to optimize reimbursement within the accepted coding guidelines and rules. Communication with physicians, physician offices and hospital staff to obtain clarifying documentation for correct coding. Applies charges on identified patients (for example ED levels, Infusions, clinic visits) based on the record documentation. Assists physicians, physician offices, medical staff and hospital personnel with HIM/coding/charging related questions. Assists with other HIM related processes i.e. release of information, deficiency analysis etc. as needed. Minimum Qualifications: CCA or equivalent certification. Relevant clinical or medical experience and CCA obtained with 1 year of hire. Knowledge, Skills & Abilities: Previous experience preferred. Knowledge of electronic record systems; knowledge of medical terminology, anatomy, physiology and disease processes; knowledge of charging processes; adept in ICD-10 and CPT coding; strong interpersonal relationships and skilled in assessing and prioritizing multiple tasks, projects and demands, operating a personal computer utilizing a variety of software applications, keyboarding skills and ability to work independently, as well as to accept direction on given assignments. Working Conditions: Work is generally performed within an office environment, with standard office equipment available. Physical Requirements: Constantly sit, see/visual acuity, handle/grasp/feel, talk/hear. Occasionally lift/carry 1 to 25 lbs.