• Codes and abstracts hospital medical records for diagnostic and procedural coding • Utilizes federal, state procedures/guidelines to assure accuracy of coding and abstracting and productivity standards • Collaborates with medical staff and clinical documentation improvement (CDI) staff to clarify documentation • Maintains performance in accordance with corporate compliance requirements as it pertains to the coding and abstracting of medical records, as well as Diagnosis Related Group (DRG) assignment • Accurately reviews each record and knowledgeably utilizes ICD-10-CM, ICD-10-PCS, CPT-4, and encoder to accurately code all significant diagnoses and procedures according to guidelines • Sequences principal diagnosis and principal procedures according to documentation found in the medical records • Utilizes ongoing knowledge and reference material regarding DRGs to validate DRG assignments • Accurately utilizes written federal and state regulations and written guidelines regarding definitions and data elements to assure uniformity of database • Verifies and/or abstracts required data into computer system according to procedure • Utilizes equipment and processes appropriately, to ensure efficient coding and abstracting • Participates in maintaining DNB and accounts receivable goal • Maintains department level competencies • Participates in performance improvement activities