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Chesapeake Regional Healthcare Coding Specialist HIM, Senior in Chesapeake, Virginia

* Fully Remote Position *

Summary

The Senior Coding Specialist is responsible for accurately assigning and sequencing ICD diagnostic and procedural codes and/or CPT procedural codes to inpatient and outpatient records.

Essential Duties and Responsibilities

  • Code diagnostic and procedural information from the record using ICD and CPT/HCPCS classification systems

  • Utilize a computerized encoding system to facilitate accurate coding

  • Sequence diagnoses and procedures by following the ICD, Uniform Hospital Data Set, Medicare, Medicaid, and other fiscal Intermediary guidelines

  • Work cooperatively with the medical staff and other healthcare professionals in obtaining documentation to complete medical records and ensure quality coding

  • Select the DRG for each inpatient discharge and APC for each outpatient visit, ensuring coding compliance based on approved coding guidelines and conventions

  • Abstract medical data from the record to complete a discharge abstract on each inpatient, ambulatory surgery, emergency room, outpatient, and ancillary visit, completing and verifying diagnostic and demographic information

  • Enter patient information into computerized inpatient and outpatient medical record databases

  • Ensure the accuracy and integrity of medical record abstract data prior to billing interface and claims submission

  • Routinely code inpatient records to meet productivity and quality standards for inpatient coding

  • Code outpatient, emergency department, and outpatient diagnostic records as determined by Coding Operations Manager

  • Consistently maintain established productivity requirements and maintain a 96% or greater accuracy rate

  • Communicate and advise the Patient Accounts on coding and DRG/APC assignment and submission

  • Assist the Coding Compliance Specialist and/or Coding Operations Manager as needed

  • Fill-in for the Coding Compliance Specialist and/or Coding Operations Manager as needed

  • Complete other duties as assigned

    Summary of Other Job Duties and Expectations

  • Adhere to the Service Excellence Standards and Expectations at Chesapeake Regional Medical Center

  • Exhibit excellent customer relations to patients, visitors, physicians, and co-workers

  • Exhibit courteous communication skills and an ability to work with others, exercising good judgment in performance of job duties

  • Demonstrate courtesy, compassion, and respect to others in adherence of the hospital's philosophy and policy for promoting positive work and customer environments

  • Work as a team to continuously improve work quality

  • Demonstrate a commitment to flexible work schedules when it is necessary to ensure patient care

  • Present self in a positive manner as reflected by personal attire, etiquette and behavior

  • Attend required hospital-wide orientations, meetings, and in-services

    Qualifications

    To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

    Education and Experience

    Minimum Required Education: Completion of a Health Information Management program with AHIMA approval status or coding program with AAPC

    Preferred Education: N/A

    Experience: 4+ years recent experience coding in an acute hospital setting required; coding ability will need to be demonstrated via a skills assessment

    Certificates, Licenses, Registrations

    Certification in RHIA or RHIT and CCS or CIC is required. In addition, also prefer outpatient coding certifications through AHIMA and AAPC.

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