Review patient medical records and documentation to identify diagnoses and procedures.
Assign accurate and complete ICD-9-CM, CPT, and HCPCS codes based on clinical documentation and coding guidelines.
Ensure coding meets all federal, state, and payer-specific requirements.
Abstract and enter coded data into electronic health records and hospital information systems.
Collaborate with clinical staff or coding team leads to clarify documentation as needed.
Maintain productivity and accuracy standards in accordance with departmental policies.
Stay current with updates to coding regulations, coding clinics, and payer guidelines.
Adhere to HIPAA regulations and all hospital confidentiality and compliance standards.
OTHER DUTIES
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice.
QUALIFICATIONS
Required:
EDUCATION: High school graduate or equivalent, associate's or bachelor's in health information management or related field preferred
EXPERIENCE:
Basic knowledge of ICD-10-CM, CPT, and medical terminology.
Strong attention to detail and analytical skills.
LICENSURE/CERTIFICATION:
Certified coding specialist (CCS) preferred or registered health information technician (RHIT) preferred
Completion of the IRMC outpatient coding competency test
Numbers & Facts
Location
Indiana, PA
Skills
Analysis Skillsunmatched
Certified Coding Specialist (CCS)unmatched
Current Procedural Terminology (CPT)unmatched
Data Entryunmatched
Detail Orientedunmatched
Documentationunmatched
HIPAA (Health Insurance Portability and Accountability Act)unmatched
Health Information Managementunmatched
High School Diplomaunmatched
Hospitalunmatched
ICD-10unmatched
Identify Issuesunmatched
Information Technology & Information Systemsunmatched
Medical Codingunmatched
Medical Record Systemunmatched
Medical Recordsunmatched
Medical Terminologyunmatched
Procedure Developmentunmatched
Registered Health Information Technician (RHIT)unmatched
Regulationsunmatched
Regulatory Complianceunmatched
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