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Coding Specialist I - Coding - HIM

Company New Hanover Regional Medical Center
Location Wilmington, NC
Update 6 Day ago
This position has access to and knowledge of extremely sensitive, private and confidential materials. Ability to maintain the highest standard is required with zero tolerance.

All the primary duties within this document will be performed according to established policies, procedures and guidelines within the department and the Medical Center.


Under the general direction of the Manager of Coding and Clinical Abstracting, this specialist is responsible for accurate coding of all ancillary and clinic visit diagnosis, procedures, and charges working from the appropriate documentation in the medical record of the patient. Classification systems include ICD-9-CM, ICD-10-CM and CPT-4. This specialist performs ongoing medical record reviews to assess completeness and timeliness of information to support services billed. This person is responsible for calculating and posting charges for facility levels, injections and infusions, and procedures for designated service areas. He/She must be knowledgeable about charge assignment, bundling, and appropriate modifier usage. The Coder I works with physicians and professional staff to obtain any necessary clarification concerning diagnosis and procedures and for monitoring reports such as the Discharges Not Final Billed (DNFB) daily schedules and timely filing lists. He/She must have a thorough understanding of facility charging guidelines, APC reimbursement, CCI rules and edits, and application of Local and National Coverage Determinations (LCD/NCDs). This person requires little supervision and performs all work independently, with a high degree of autonomy. All work is carried out in accordance with the department's approved policies and procedures. This position is an advanced level technical position within the Coding Department.


1. Codes all diagnoses and procedures for ancillary and clinic services according to the appropriate classification system for that category of patient encounter, and in accordance with provisions of the Uniform Hospital Discharge Data Set as well as the interpretation of these provisions as issued by the American Hospital Association and American Health Information Management Association and all governmental and private Third Party rules and regulations.

2. Abstracts patient information from records of all assigned accounts and enters appropriate data elements into the computerized abstracting system.

3. Calculates and posts charges for facility levels, injections and infusions, and procedures for designated service areas. Adds appropriate modifiers and reviews accounts for charge errors. Performs or refers charge corrections to appropriate resource to ensure accurate billing.

4. Consistently meets (100%) coding productivity target and accuracy requirements (95% or higher).

5. Completes continuing education as required to maintain competency and credentials (if applicable) as well as to stay current with coding rules and guidelines.

6. Collaborates with physicians and other direct patient care professionals in questions regarding level of detail for diagnostic entries, according to the organization's guidelines.

7. Promotes public relations through prompt and courteous service.

8. Fosters respect for patient privacy by maintaining confidentiality in all phases of work.

9. Performs those duties necessary to ensure all accounts are processed accurately and efficiently.

10. Maintains a successful working relationship with employees, medical staff, and other departments.

11. Effectively demonstrates the mission, vision, and values of the medical center on a daily basis.

12. Performs other duties as assigned.


1. Education: High school diploma required. Advanced medical terminology, clinical medical concepts, and human anatomy and physiology required. Education may be through formal programs of study or through sequenced in-service training. Must possess equivalent training or experience in ICD-9-CM, ICD-10-CM and CPT coding classifications, advanced medical and anatomical terminology, clinical medicine theory, and reimbursement principles.

2. Licensure / Certifications: None required, CPC, CCA, CCS, RHIT, or RHIA preferred.

3. Experience: At least one year coding/abstracting required, coding experience in an acute care setting, as well as experience with encoding software and electronic medical records preferred.