1. Analyzes, sequences and validates assigned codes based on medical record documentation using the automated encoder, book and coding compliance resources.

2. Demonstrates complete understanding of coding rules, anatomy, physiology, and medical terminology to appropriately code patient information.

3. Reviews all medical record documentation to determine and assign diagnoses, procedures, level codes and modifiers, to ensure appropriate coding for case mix.

4. Selects the appropriate reimbursement grouper based on financial class for the particular account.

5. Ensures that coding compliance, regulatory and reimbursement requirements are met through the process of assigning reimbursement classifications.

6. Abstracts and enters diagnosis, procedures and level codes with demographic, clinical and related patient information into the Medical Record Abstracting and/or Billing/Accounts Receivable systems.

7. Assess adequacy of documentation and queries physicians and other healthcare providers to obtain additional medical record documentation or to clarify documentation to ensure accurate and appropriate coding and grouping.

8. Reconciles, identifies and retrieves medical records to be coded, grouped and abstracted in accordance with departmental procedures.

9. Maintains a 95%25 ongoing accuracy rate based on Medical Record Department performance monitors and third party validation audits.

10. Consistently achieves weekly coding output within the minimal productivity standards set by HIS. Self-manages and prioritizes work flow to achieve timely submission of claims and optimal productivity.11. Maintains accurate productivity logs and provides this information to the Coding Manager in a timely fashion.12. Assists in the orientation and development of new coding personnel.13. Assumes professional responsibility for development of skills and ongoing education to maintain certification.

14. Remains abreast of developments in health information management by pursuing a program of professional development, attending educational programs and meetings and reviewing pertinent literature.15. Continuously monitors medical record documentation, 3M coding system, Soarian Financials system, SSI claim scrubber system, individual performance and department workflow as related to the coding function to identify problems and potential solutions (especially related to errors and compliance issues). Communicates with the Coding Manager to find solutions and implement changes to increase productivity and department efficiency.

16. Performs all duties and interacts with others in accordance with the Hospital's Customer Service standards.

17. Perform other work related duties as assigned or requested.

Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers in a manner that reflects Cape Cod Hospital’s commitment to CARES: compassion, accountability, respect, excellence and service.

Grade S15/Job Code 9164

· Ability to read, write and communicate in English

· Current CCS (AHIMA Certified Coding Specialist)

· 6 months of PC windows experience.

· 6 months of inpatient coding experience.

· Successful passage of Medical Record Department Inpatient Coding exam with a grade of 80%25 or better.