Coding Specialist

Review of medical record documentation submitted by clinician with subsequent assignment of proper International Classification of Disease numerical codes.

Must have HCS-D Certification

Remote Position

• Thoroughly reviews the medical record as part of the coding process in order to assign and report the most appropriate codes.
• Adheres to all official coding guidelines as approved by the Public Health Service and the Centers for Medicare and Medicaid Services.
• Selects the principal diagnosis according to CMS definitions, and observe sequencing rules identified by the ICD guidelines
• Assigns and report codes, without physician or clinician consultation, to diagnoses only if these diagnoses are specifically documented by the physician in the body of the medical record and the documentation is clear and concise
• Assesses clinical documentation to assure that it supports the diagnosis codes selected.
• Consults the clinician via electronic alerts for clarification when conflicting or ambiguous documentation is present, and for the clinician's acceptance or declination of changes.
• Revises codes reported when the physician or clinician disagrees with the code selection.
• Provides coding and classification systems education to any and all clinicians when opportunities arise (e.g. provide pertinent official coding guidelines when the clinician questions a code assignment).
• Maintains a positive working relationship with clinicians through ongoing communication and open dialogue.
• Seeks clarification, using all available references, when a specific code for a listed condition cannot be located.
• Responsible for daily completion of assigned coding tasks.
• Responsible to follow work flow|process exactly as outlined in training material without deviation.
• Productivity as defined upon hire must be met by second month post orientation.
• Perform other Duties as assigned timely and effectively.
• Participates in staff meetings and educational sessions.

• Experience: 1 year
• Must be a Clinician or a Registered Health Information Administrator (RHIA) or be certified as a Home Care Specialist - Diagnosis (HCS-D).
• Must maintain HCS-D certification annually.
• One (1) year of experience preferred.
• Effective Verbal and Communication