Job Overview
JOB DETAILS
REQUIREMENTS
- High School or equivalency diploma required
- College degree preferred
RESPONSIBILITIES
- Using the coding system, assigns and records an accurate code to all diagnoses, procedures, and operations as documented in the patient medical record based on official coding guidelines
- Ensures that all factors necessary for assigning an accurate DRG (Diagnostic Related Group) are present, and that all diagnoses are ranked properly
- Contacts hospital designee regarding questions on diagnoses, need for greater detail or different terminology to assign accurate codes to medical records
- Enter final diagnostic codes for diagnoses and procedures into an automated grouper system
- Complies with internal procedures established to ensure compliance with regulatory agencies for all facilities
- Reports on potential coding discrepancies to HIM/Medical Records Manager and Business Office Manager to assure that only accurate and properly documented services are coded in accordance with Federal False Claims
- Provides information and responds to inquiries regarding medical documentation and DRGs to hospital staff
- Conducts job responsibilities in accordance with the standards set out in the Company’s Code of Business Conduct, its policies and procedures, our client’s Compliance Agreement, applicable federal and state laws, and applicable professional standards
- Promotes adherence to the Company’s Code of Business Conduct and our client’s Compliance Agreement by monitoring employee performance and identifying and responding to compliance issues
- Abstracts and retrieves medical data for evaluation, planning, or research in health care and related programs
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