Assistant Clinical Coder-Coding

 Responsible for abstracting and analyzing clinical information from medical records and relevant documents, translating the information into diagnostic and operative procedure codes in accordance with the clinical coding system.

•   Assigns  codes  for  diagnoses,  treatments,  and  procedures  according  to  the  appropriate classification system outpatient (OP)/emergency department (ED) or observation short stay. 
•   Oversees and reviews provider documentation to determine principal diagnosis, comorbidities and complications, secondary conditions and surgical procedures. 
•   Adheres to official coding guidelines when coding with accuracy and completeness as supported by documentation. 
•   Ensures accurate coding by clarifying diagnosis and procedural information through a query process. 
•   Assigns Present on Admission (POA) value for inpatient diagnoses. 
•   Ensures accurate physician name against each service and accurate time and date. 
•   Interacts with physicians and other areas when additional coding information is needed; for example to prevent medical necessity denials. 
•   Prepares  and  reviews  documentation  to  verify  and  when  necessary,  correct  the  patient disposition upon discharge. 
•   Maintains the assigned target of production and accuracy of Coding. 
•   Prioritizes  work  to  ensure  the  timeframe  of  medical  record  coding  meets  regulatory requirements. 
•   Engages with the physicians in the Coding Query process and provides training as necessary. 
•   Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines. 
Accountabilities 
•    Ensures that codes are assigned correctly and sequenced appropriately as per government and insurance regulation 


 

Experience :-  
Required: 
•   3 years of relevant progressive experience in a similar role. 

Desired: 
•   Experience in a large healthcare facility 
 Educational Qualification: Required: 
•   Bachelor Degree in Health Information Management or relevant field with or Diploma with 3 years of additional experience in Healthcare 

Desired: 
•   N.A.