Full job description

The incumb e nt c h e c ks a nd s e qu e n c e s the most acc u r a te I C D - 9/ ICD10- CM/C P T/H C P C S /DRG / Oth e r c od e s for di a g n o s e s a nd p r o ce dur e s f o r do c ument e d info r mation. Assu re s the fin a l dia g no s e s a nd o p e r a t i ve p r o ce du r e s a s stat e d b y the p h y sici a n a re v a l i d a nd c omp l e te.

3.2 Abstr ac ts a ll n e c e ssa r y info r mation f rom h ea l t h r e c o r ds to identi f y s ec on d a r y c omp l ic a t i ons a nd c o - m o rbid c ondi t ions.

3.3 Ev a luat e s the re c o r d for do c ument a t i on c onsiste n c y a nd a d e q u a c y . Ensu r e s that the fin a l dia g nosis acc u r a te l y refl ec ts the ca r e a nd treatment rendered. Computes and gives the correct DRG c odi n g a ll inpatients cases.

3.4 P roviding tr a in i n g a nd guid i ng other c o d e rs / M e dic a l R ec o r ds T ec hnici a n s in c odin g , up d a t i ng them w i th new c oding ru l e s and r e g u l a t i ons a s a n d wh e n it is ne ce ssa r y .

3.5 An a l y z e s do c tors’ d o c ument a t i on to a ssure the a ppro p ri a te Ev a luation &

Mana g e ment ( E & M) l e v e ls a r e a ss i g n e d using t h e c o r r ec t CP T c od e .

3.6 Ensur e s co d i n g is a s p e r H A AD g uidelines a nd re g ulation s .

3.7 P rovid e s f ee d b ac k to D o c tors r e g a r d i n g c odi n g e r ro r s or ov e rsi g hts.

• Assign accurate ICD-9-CM, ICD-10-CM, CPT, HCPCS, DRG, and other applicable codes for diagnoses and procedures based on clinical documentation.
• Validate that final diagnoses and operative procedures documented by physicians are complete and accurately coded.
• Abstract relevant information from health records to identify secondary diagnoses, complications, and co-morbidities .
• Review medical records for documentation consistency, completeness, and adequacy .
• Ensure the final diagnosis reflects the care and treatment provided and assign the correct DRG for all inpatient cases.
• Provide training, guidance, and mentorship to Medical Coders and Medical Records Technicians on coding practices and regulatory updates.
• Analyze physicians' documentation to ensure accurate assignment of Evaluation & Management (E&M) levels using the appropriate CPT codes .
• Ensure compliance with DOH (formerly HAAD) coding guidelines, regulations, and coding standards .
• Provide constructive feedback to physicians regarding coding discrepancies, documentation gaps, and missed coding opportunities.

• Bachelor's Degree in Allied Health Sciences or a related field.
• Minimum 2 years of medical coding experience .
• Valid Certified Coding Associate (CCA) certification from AHIMA or Certified Professional Coder (CPC) certification from AAPC .
• Proficient in MS Office and general computer applications.
• Excellent written and verbal communication skills in English.

Competencies

• Achieve assigned objectives in line with organizational and stakeholder expectations.
• Demonstrate professionalism and collaborate effectively with multidisciplinary teams.
• Manage multiple tasks efficiently, adapt to changing priorities, and meet deadlines.
• Willingness to attend meetings outside normal working hours when required.
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