The HIM Coding Specialist reviews the patient’s medical record to assign the appropriate diagnoses codes,
procedure codes, DRG/APC assignments.
Follows all UHDDS, AHA, ICD-10 and CPT coding guidelines.
Assigns appropriate admission/discharge disposition present on Admission indicators and any additional
required data elements.
Contacts physicians as needed for clarification regarding the assignment of diagnostic and procedural codes.
Collaborates with the Clinical Documentation Specialist team to ensure appropriate clinical documentation
within the patient's medical record to support the final coding process.
Ensures established quality, productivity and process goals are met.
Ensures compliance with Medicare and other required regulatory agency guidelines related to coding.
High School Diploma or GED (Required)
**Non Degree Program: i.e. Completion of a Coding Program (Required)
2 year / Associate Degree: Health information Management Technician (Preferred)
**Combination of relevant education and experience may be considered in lieu of degree
Certification and Licensure Requirements:
*Coding certificate (preferably AHIMA approved) or coding credential (CCS, CCA, CCS-P, CPC) (Required or
obtained within 1 year of employment)
AHIMA RHIA (Preferred)
AHIMA RHIT (Preferred)
Experience and Skills
1-3 years knowledge of medical terminology, anatomy and physiology, pathophysiology, ICD-9-CM, basic
CPT4 classifications systems, prospective payment systems, 3rd party reimbursement and select regulatory
agency requirements (Required)
1-3 years strong analytical and investigative skills in order to assign appropriate diagnostic and procedural
codes and to maintain data integrity. (Required)
1-3 Years Experience working with electronic coding systems, electronic health records (Preferred)
ICD 10 Training/Experience (Preferred)
Required Skills: Excellent Communications Skills, Excellent Interpersonal Skills, General Clerical Skills, Basic
computer skills (Microsoft office, HIM Electronic Health Record, etc), basic knowledge of standard office