This position is OFFSITE / REMOTE

Part-time w/possibility of Full-time hours as needed

Summary:
Primarily Outpatient Coding; - Same day Surgeries and secondary ED coding as needed. 
All work is performed in accordance with the rules, regulations and coding conventions as established by the American Hospital Association (Coding Clinic), ICD-10, CMS, OSHPD and Clients organizational/institutional coding guidelines.

Education/License/Certification:
This position requires a a Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA).
Completion of classes in medical terminology, anatomy and physiology, ICD-10 and CPT coding conventions, and disease process from an accredited program.
Must have high school diploma or GED. 

Qualifications:
Must have two years of continuous hospital experience in coding/abstracting within the last five years.
Demonstrated ability to understand the clinical content of a health record.
Demonstrated ability to communicate with physicians in order to clarify diagnoses/procedures and sequencing of diagnoses.
Must be able to meet quantity and quality standards established for Coders I Basic PC skills.
Must attain a grade of 75% on the coding test.
Must maintain a minimum of ten (10) CE units annually.
Must maintain current coding credential.
Will abide by the AHIMA coding code of ethics.

Duties:
Review medical records to identify diagnoses/procedures.
Under general supervision, organizes and prioritizes all work to ensure that records are coded in timeframes that will assure compliance with regulatory requirements.
Demonstrates knowledge of all procedures concerning the sequencing of diagnoses, procedures as outlined in but not limited to ICD-10-CM, CPT, Uniform Hospital Discharge Data Set, Medicare guidelines and other appropriate classification systems.
Demonstrates knowledge of anatomy and physiology to interpret general medical classifications for coding outpatient encounter or inpatient discharge data.

Assigns Codes:
Under direct supervision: Codes all diagnostic and operative information from the medical record using ICD-10-CM, CPT, HCPCS level 2 coding classification systems for the following encounters: Hospital Ambulatory Surgery (Same day Surgeries), Observation and Outpatient Procedures like Cardiac Cath, Electrophysiology, Pain Management and Interventional Radiology encounters.
Verifies and abstracts all medical data from the record to complete a data abstract on hospital encounters.
Corrects data as appropriate.
Ensures that all data abstracted and/or coded are consistent with guidelines outlined by TJC, OSHPD and CMS, regional and local policy. 

Completion of Medical Records under general supervision, interacts with physicians to clarify and accurately document patient diagnostic and procedural information.
Enters patient information into the computerized inpatient and outpatient medical record databases, ensuring the accuracy and integrity of the medical record abstract or encounter data prior to transmitting case.
Ensures timely record availability by meeting coding and abstracting productivity / quality standards established for Coders I.
Participates in medical record documentation auditing to monitor physician compliance with regulatory requirements i.e., Physician Review Project. 

Physical and Mental Demands.
Ability to sit for long periods of time.
Ability to withstand the pressure of continual deadlines and receipt of work with variable requirements.
Ability to concentrate and maintain accuracy in spite of frequent interruptions.
Manual dexterity.