Job Description

General Summary of Position
Codes and abstracts primarily Inpatient records using ICD-10-CM and other applicable patient classification schemes.

Minimum Qualifications
Education

• High School Diploma or GED Required or
• equivalent. Required and
• Associate\'s degree in coding related degree Preferred or
• Bachelor\'s degree in coding related degree Preferred and
• Courses in Medical Terminology, Anatomy & Physiology, ICD-CM and ICD-PCS Required

Experience

• 3-4 years Inpatient coding experience Required
• Experience with clinical information systems (3M grouper, electronic medical records, computer assisted coding) Preferred

Licenses and Certifications

• CCS (Certified Coding Specialist) Required and
• RHIT (Registered Health Information Technician) Preferred and
• RHIA (Registered Health Information Administrator) Preferred and

Knowledge, Skills, and Abilities

• Verbal and written communication skills.
• Basic computer skills required.

Primary Duties and Responsibilities

• Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.
• Abstracts and ensures accuracy of diagnoses, procedure, patient demographics, and other required data elements.
• Adhere to all compliance regulations and maintains annual compliance education.
• Maintains continuing education and seeks ongoing education to improve job performance. Maintains credentials as required for job classification.
• Contacts physician when conflicting or ambiguous information appears in the medical record. Adheres to the MedStar Coding Query Policy and procedure.
• Meets established Quality standards as defined by policies.
• Meets established Productivity standards as defined by policies.
• Resolves all quality reviews timely (e.g. Medical necessity reviews; Coding Quality assurance reviews; external vendor reviews).
• Reviews medical record documentation to identify diagnoses and procedures. Assigns correct diagnostic and procedural codes using standard guidelines and automated encoding software maintaining departmental accuracy standards. Determines the sequence of diagnoses according to Uniform Hospital Discharge Data Definitions and assigns appropriate DRG (Diagnosis Related Groups).
• Exhibits knowledge of the 3M system and other work-related equipment.
• Participates in meetings and on committees and represents the department and hospital in community outreach efforts.
• Participates in multi-disciplinary quality and service improvement teams.
• Performs other duties as assigned.

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Why MedStar Health?
At MedStar Health, we understand that our ability to treat others well begins with how we treat each other. We work hard to foster an inclusive and positive environment where our associates feel valued, connected, and empowered. We live up to this promise through:

• Strong emphasis on teamwork\xe2\x80\x94our associates feel connected to each other and our mission as an organization. In return, our effective team environment generates positive patient outcomes and high associate satisfaction ratings that exceed the national benchmark.
• Comprehensive total rewards package\xe2\x80\x94including competitive pay, generous paid time off, great health and wellness benefits, retirement savings, education assistance, and so much more.
• More career opportunities closer to home\xe2\x80\x94as the largest healthcare provider in the Baltimore-Washington, D.C. region, there are countless opportunities to grow your career and fulfill your aspirations.

About MedStar Health
MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It\xe2\x80\x99s how we treat people.

Medstar Health