Clinical Coder III - Day Surgery - observation

Overview

Job Summary

Reviews moderate to high complexity medical records to identify the appropriate principal diagnosis and procedure and all other appropriate secondary diagnoses and procedures. Assigns codes based on clinical documentation including procedures utilizing International Classification of Disease (ICD), Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS). Serves as a subject matter expert in your assigned specialty and actively participates in coding meetings as a problem solver.

Essential Functions

• Reviews moderate to high complexity medical records to identify the appropriate principal diagnosis and procedure codes and all other appropriate secondary diagnoses and procedure codes
• Basic knowledge of pharmacology indications for drug usage and related adverse reactions.
• Effective communication skills (oral and written) and interpersonal skills.
• Good organization, prioritization, and reading comprehension skills.
• Good analytical skills, with attention to detail.
• Ability to work independently and exercise independent judgment and decision making.
• Ability to meet deadlines while working in a fast-paced environment.
• Must be able to work independently in a fully remote environment.
• Abstracts coded data and other pertinent fields in the hospital electronic health record. Ensures the accuracy of data input.
• Meets established quality and productivity standards.
• Stay abreast of coding principles and regulatory guidelines related to inpatient and/or outpatient coding.
• Must be able to sit for extended periods of time.
• Must be able to continuously concentrate.
• Position may require some travel to other sites; therefore, may be exposed to road and weather hazards.
• Operates all equipment necessary to perform job duties as assigned.

Physical Requirements
Must be able to concentrate and sit for long periods of time while reviewing electronic health records. Daily and weekly deadlines must be met in a fast paced office environment and/or at home environment.

Education, Experience and Certifications.
High School Diploma or GED required; Bachelor's Degree preferred. Advanced knowledge in Medical Terminology, Anatomy and Physiology and Pharmacology required. 2 years coding experience in acute care setting required. Current RHIT, RHIA, CPC-H, CIC or CCS required plus a passing score on the Coding test.

Preferred: