Job Requirements POSITION SUMMARY To be fully engaged in providing timely, complete, and accurate code assignment and data collection for quality clinical analysis and revenue enhancement. PRIMARY ACCOUNTABILITES * Uphold regulatory compliance by assigning and sequencing accurate ICD 10 codes to inpatient medical records as per coding guidelines demonstrating behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities. * Validates the accuracy of codes assigned by the computer assisted coding software, recognizing inappropriate application of clinical coding regulations/guidelines, and revising the codes assigned based on expert subject matter knowledge and provider documentation. * Literacy and proficiency in computer technology, particularly related to health information and coding applications utilized for daily job performance, are essential. * Interpret clinical documentation to ensure codes reported are clearly and consistently supported by the health record. * Examine and ensure that the MS-DRG, APR-DRG, SOI, and ROM of each inpatient encounter is compatible and compliantly optimized. * Request clarification from the provider when there is conflicting, incomplete, or incorrect information in the health record regarding a significant reportable condition or procedure or other reportable data element collaborating with the Clinical Documentation Specialists regarding concurrent and post-discharge queries to the providers, ensuring physician responses to queries are reflected in the code assignment. * Abstract relevant information accurately and completely into the computer assisted coding application, including but not limited to present on admission indicators, * consulting physicians/dates, surgeons/dates, and birthweight of infants. Verify and revise according to documentation in the medical record the correct discharge disposition of encounters coded. * Confirm the admission status ordered by the physician in the medical record documentation and the registration status of the encounter are compatible. * Communicates professionally identified discrepancies, documentation issues, denial management issues and coding concerns in the medical record to the appropriate department and/or leader. * Stays up to date with regulatory changes by completing all mandatory educational accountabilities in a timely manner. * Maintain coding quality and productivity as per departmental standards. * Attends department meetings and other inpatient coding sessions as scheduled. * Accurate and ethical time and attendance recording ensure that non-productivity logs are completed and submitted by the deadline set. * Provide departmental coding coverage by cooperating with occasional schedule revisions and overtime requests when staffing needs arise assisting with maintenance of discharge not final coded (DNFC) departmental goals. * Maintain and observe patient confidentiality as outlined in the National Patient Safety Goals and HIPAA guidelines always protecting the confidentiality of the health record * and refusing to access protected health information not required for coding-related activities. Work Experience MINIMUM QUALIFICATIONS * Education:High School Diploma * Work Experience:4 Years Inpatient Coding Experience * Licensure:N/A * Certification:AHIMA or AAPC Inpatient Coding Certification * Work Experience in lieu of Certification:8 Years Inpatient Coding Experience * Skills/Knowledge/Abilities: * Competent in understanding medical terminology. * Advanced understanding of anatomy and physiology. * Utilize critical thinking skills and formulate logical decisions to apply clinical coding guidelines to health record documentation. * Strong written and oral communication skills for professional interaction. * Excellent computer and telephone skills. * Must be detail and accuracy oriented. * Ability to coordinate and use logical reasoning to facilitate daily workflow assignments. * Ability to work independently maintaining focus on scope of work assigned. PREFERRED QUALIFICATIONS * Work Experience:6 Years Inpatient Coding Experience PHYSICAL REQUIREMENTS * Majority of time involves sitting or standing; occasional walking, bending, and stooping. * Long periods of computer time or at workstation. * Light work that may include lifting or moving objects up to 20 pounds with or without assistance. * May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise. * Communicating with others to exchange information. * Visual acuity and hand-eye coordination to perform tasks. * Workspace may vary from open to confined, onsite, or remote. * May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle.