Department: CNEMG-WIH PEDIATRICS
Operating Unit: Care New England Medical Group
Location: Providence, RI
Job ID: 20772
Job Status: Part Time
Shift: Days
Schedule: To be discussed at time of interview
*This is NOT a remote position*
Job Summary: Responsible for accurate coding of outpatient and inpatient professional services, procedures, diagnoses, and conditions, working from the appropriate documentation in the medical record. Classification systems include ICD-9-CM, CPT, HCPCS as well as other specialty systems as required by diagnostic category. All work carried out in accordance with the rules, regulations, and coding conventions of the American Association of Professional Coders (AAPC) ICD9 (and ICD10 when implemented), AMA CPT, and CMS coding guidelines. As needed, Coders may assist and be a resource for data integrity for other employees who need clarification and assistance in coding.
Duties and Responsibilities:
- Review medical records to identify procedures/diagnoses.
- Demonstrate a comprehensive, expert-level of knowledge of all procedures concerning the sequencing of diagnoses, procedures such as but not limited to those outlined in ICD-9-CM, (and ICD10 when implemented), CPT, Medicare guidelines and other appropriate classification systems.
- Demonstrate knowledge of anatomy, physiology, pharmacology, and pathophysiology to interpret general medical classifications for coding discharge data.
- Assign Codes and code all diagnostic and operative information from the medical record using ICD-9-CM, ICD-10, CPT, and HCPCS coding classification systems and independently quality check own work.
- Ensure that all data abstracted is consistent with guidelines outlined by JCAHO, and CMS, regional and local policy.
- Interact with physicians to clarify and accurately document patient diagnostic and procedural information.
- Enter patient information into the computerized outpatient medical record databases.
- Ensure timely record availability by meeting established coding and abstracting productivity standards.
- Maintain and comply with policies and procedures for confidentiality of all patient records.
- Act as an expert resource.
- Perform other related duties as assigned.
Requirements:
- Certification as a Certified Professional Coder (CPC) or Certified Coding Specialist (CCS).
- Minimum one (1) year coding experience within the last three years.
- Completion of classes in medical terminology, anatomy and physiology, ICD-9 and CPT coding conventions, and disease process from an accredited program or equivalent experience. Must maintain current coding credential.
- Ability to demonstrate knowledge of and utilize auditing skills related to coding quality and compliance.
- Ability to understand the clinical content of a health record, including the most complicated records. Must also be able to communicate with physicians in order to clarify diagnoses/procedures and sequencing of diagnoses. Will abide by the AAPC or AHIMA coding code of ethics.
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