**Job Type:** Per Diem **Time Type:** Part time **Work Shift:** Day (United States of America) **FLSA Status:** Non-Exempt **When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.** Per Diem; Based on department needs **Job Description:** **Duties/Responsibilities:** + Reads Patient records and as needed, discusses patient conditions with physicians to accurately and completely apply diagnostic, procedural and service codes to each patient condition treated (including operations) during an outpatient encounter. + Abstracts clinical data from patient records and enters data into computer databases. Serves as the source of clinical data for reimbursement, planning and research. Completely codes/abstracts outpatient records. + Analyzes patient medical records and interprets documentation to identify all diagnoses and procedures. Assigns proper ICD-10-CM and/or CPT diagnostic and operative procedure codes to charts and related records by reference to designated coding manuals and other reference material.a. Codes and abstracts records consistently with 95% accuracy rate based on Medical Record Department performance monitors and third party validation audits.b. Maintains with five (3) days after discharge coding requirements.c. Consistently achieves weekly coding output within the minimal productivity standards set by HIS. Self-manages and prioritizes work flow to achieve timely submission of claims and optimal productivity. + Applies Uniform Hospital Discharge Data Set definitions to select the principal diagnosis, principal procedure and other diagnoses and procedures which require coding, as well as other data items required to maintain the Hospital database.a. Verifies that coded information is entered into the databases without any errors within five (s) days of patient discharge. + Applies sequencing guidelines to coded data according to official coding rules. + Assesses the adequacy of medical record documentation to ensure that it supports the principal diagnosis, principal procedure, complications and comorbid conditions assigned codes. Consults with the appropriate physician and/or parties to clarify medical record information.a. Identifies any documentation inadequacies with physician and/or appropriate parties and clarifies medical record information with courtesy and tact.b. Keeps abreast of reimbursement reporting requirements, ie: medical necessity policies. + Answers physicians/clinical questions regarding coding principles. Assists Finance, Data Processing and other departments with coding issues.a. Assists physicians and ancillary departments with coding questions with timeliness, courtesy and tact.b. Works billing edits through claims and denial software. + Remains abreast of development in medical record technology by pursuing a program of professional growth and development, attending educational programs and meetings, reviewing pertinent literature.a. Utilizes professional affiliations, etc., in order to maintain current in professional developments.b. Attends pertinent coding seminars, when available.c. Maintains updated coding books. + Embraces technological solutions to work processes and practices. + Safety Awareness-fosters a “Culture of Safety” through personal ownership and commitment to a safe environment. _It is understood that this is a summary of key job functions and does not include every detail of the job that may reasonably be required._ **Education/Experience Required:** + Six months to one year acute care related outpatient coding experience required + Demonstrates knowledge of ICD-10-CM and CPT-4/HCPCS to accurately code and abstract encounters. + PC Windows experience + Working knowledge of 3M coding software and Meditech Abstracting preferred. + Typing skills of 35 WPM. + Medical Terminology + ICD-10-CM and CPT coding ability **Registration/Certification:** + Current CCS, CCS-P, CPC, OR CPC-H certification + Registered Health Information Technician (RHIT) preferred. **As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more (https://www.bilh.org/newsroom/bilh-to-require-covid-19-influenza-vaccines-for-all-clinicians-staff-by-oct-31) about this requirement.** **More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.** **Equal Opportunity** **Employer/Veterans/Disabled**