Assistant Clinical Coder-Coding

Responsible for abstracting and analyzing clinical information from medical records and relevant documents, translating the information into diagnostic and operative procedure codes in accordance with the clinical coding system.

• Assign codes for diagnoses, treatments, and procedures according to the appropriate classification system outpatient (OP)/emergency department (ED) or observation short stay.
• Oversee and review provider documentation to determine principal diagnosis, comorbidities and complications, secondary conditions and surgical procedures.
• Adhere to official coding guidelines when coding with accuracy and completeness as supported by documentation.
• Ensure accurate coding by clarifying diagnosis and procedural information through a query process.
• Assign Present on Admission (POA) value for inpatient diagnoses.
• Ensure accurate physician name against each service and accurate time and date.
• Interact with physicians and other areas when additional coding information is needed to prevent medical necessity denials.
• Prepare and review documentation to verify and, when necessary, correct the patient disposition upon discharge.
• Maintain the assigned target of production and accuracy of coding.
• Prioritize work to ensure the timeframe of medical record coding meets regulatory requirements.
• Engage with physicians in the coding query process and provide training as necessary.
• Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adhere to official coding guidelines.

• Ensure that codes are assigned correctly and sequenced appropriately as per government and insurance regulation.

• 3 years of relevant progressive experience in a similar role.

• Experience in a large healthcare facility.

• Bachelor Degree in Health Information Management or relevant field with or Diploma with 3 years of additional experience in Healthcare.

• N.A.