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Work Shift
Day (United States of America)
Job Summary:
The Facility Surgical Coder 2 position reports directly to the Supervisor of Coding.
Key responsibilities of the role include:
- Reviewing documentation in same day surgery and observation medical records, and accurately and completely assigning appropriate ICD-10-CM diagnostic and procedural CPT-4/HCPCS codes to the greatest specificity and assigning the most accurate APC when appropriate. Abstracts demographic and coding information accurately and completely
Core Responsibilities and Essential Functions:
- Codes and abstracts medical records with a minimum of accuracy.
- Accurately and completely assigns appropriate ICD-10-CM diagnostic and CPT-4/HCPCS procedural codes to the greatest specificity, assigning the most accurate DRG/APC, when appropriate and in accordance with Official Guidelines for Coding and Reporting and Facility Coding Guidelines, as applicable
- Accurately and completely abstracts all required patient demographic data into the EMR
- Accurately assigns correct APC
- Meets productivity standards
- Queries providers, if needed to further clarify code
- Manages additional coding responsibilities, contributing to the CFB (candidate for bill) goals, including but not limited to: resolving coding edits and reminders, correcting abstracting and coding issues in a timely manner (1-2 business days)
- Completes and routes problem accounts, ready to code, high dollar and other accounts daily to ensure cases are coded as close to goal date as possible
- Completes assigned work by goal date
- Assists with coding unassigned or backlogged accounts
- Accurately capture the surgical CPT code(s) for pre-certification reconciliation for each of the WHS facilities, as needed
- Serves as a mentor to new coders
- Assist with cleaning up or escalating missing documentation or other work queues
- If proficient, assists with outpatient and emergency coding when needed or assigned
- Performs other duties as assigned
- Complies with all WellStar Health System policies, standards of work, and code of conduct.
Required Minimum Education:
- High School Diploma or GED
Preferred Certification(s):
All certifications are required upon hire unless otherwise stated.
- CCS - Cert Coding Spec Upon Hire Preferred or
- CPC - Cert Prof Coder Upon Hire Preferred or
- RHIA - Reg Health Information Admin Upon Hire Preferred or
- RHIT - Reg Health Information Tech Upon Hire Preferred or
Required Minimum Experience:
Minimum 3 years acute care same day surgery and observation coding experience.
Required Minimum Skills:
- Must have demonstrated maintenance of a or higher accuracy in abstracting, code and DRG assignment while meeting productivity requirements in previous roles.
- Ability to work in a remote environment. Computer/data entry experience.
- Ability to communicate with various members of the healthcare team.
- Ability to use Microsoft (Excel, Word).
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