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

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

2.    Utilize a computerized encoding system to facilitate accurate coding

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

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

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

6.    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

7.    Enter patient information into computerized inpatient and outpatient medical record databases

8.    Ensure the accuracy and integrity of medical record abstract dataprior to billing interface and claims submission

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

10. Code outpatient and ancillary records as determined by Coding Manager

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

12. Communicate and advise the Business Office on coding and DRG/APC assignment and submission

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

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

15. Complete other duties as assigned

Education and Experience

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

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 is required.