Clinical Coder - Trauma Registrar - Acute Care

Job Summary

Reviews clinical documentation and diagnostic results as appropriate to abstract data and apply appropriate ICD-9-CM/ICD-10-CM/PCS codes and CPT 4 codes for reimbursement and external reporting, research and regulatory compliance and medical necessity, CCI, NCCI and any other regulatory edits. Coding and abstract medical records of low complexity within the Primary Enterprise acute care facilities.

Essential Functions

• Reviews low complexity medical records to identify the appropriate principal diagnosis and procedure and all other appropriate secondary diagnoses and procedures.
• Reviews charges including Evaluation and Management levels.
• Demonstrates the technical competence to use the facility encoder as it interfaces with the hospital mainframe and/or EMR in an on-site or remote setting.
• Abstracts coded data and other pertinent data in the hospital electronic health record.
• Ensures the accuracy of data input.
• Meets established quality and productivity standards.
• Stays abreast of coding principles and regulatory guidelines related to outpatient coding.

Physical Requirements
Must be able to concentrate and sit for long periods of time while reviewing electronic health records. Daily and weekly deadlines must be met in a fast paced office environment and/or at home environment.

Education, Experience and Certifications.
High School Diploma or GED required. Courses in Medical Terminology, Anatomy & Physiology and Pharmacology preferred. Coding Experience Preferred. CCA or CPC-A required or must be obtained within one year. Current RHIA, RHIT, CCS, CCS-P, CPC, CPC-H (COC), CIC preferred plus a passing score on the Coding test. Proficient with Microsoft Office Applications required.