Responsible for abstracting, coding, sequencing and interpreting the clinical information from inpatient, outpatient, emergency department, pro fee, and clinical medical records. 

Responsible for the assignment of correct principal diagnoses, secondary diagnoses and principal procedure and secondary procedure codes with attention to accurate sequencing. 

Utilizes technical coding principals and DRG/APC reimbursement expertise to assign appropriate codes. 

Abstracts and codes pertinent medical data into multiple software programs and/or encoders. Follows official coding guidelines to review and analyze health records. 

Maintains compliance with both external regulatory and accreditation requirements, and with State and Federal regulations. 

Extracts pertinent data from the patient’s health record and determines appropriate coding for reports and billing documents. 

Identifies codes for reporting medical services, procedures performed by physicians. Enters codes into various computer systems dependent upon the various clients. 

Track and document productivity in specified systems, maintain productivity levels as defined by the client. 

Maintain 95% quality rating 

Perform duties in compliance with Company’s policies and procedures, including but not limited to those related to HIPAA and compliance. 

Ability to prioritize and multi-task in a fast-paced, changing environment. 

Demonstrate ability to work in all work types and specialties. 

Demonstrate ability to self-motivate, set goals, and meet deadlines. 

Demonstrate leadership, mentoring, and interpersonal skills. 

Demonstrate excellent presentation, verbal, and written communication skills. 

Ability to develop and maintain relationships with key business partners by building personal credibility and trust. 

Maintain courteous and professional working relationships with employees at all levels of the organization. 

Demonstrate excellent analytical, critical thinking and problem-solving skills. 

Skill in operating a personal computer and utilizing a variety of software applications. 

Knowledge of coding convention and rules established by the AHIMA, American Medical Association (AMA), the American Hospital Association (AHA) and the Center for Medicare and Medicaid (CMS), for assignment of diagnostic and surgical procedural codes. 

Knowledge of JCAHO, coding compliance and HIPAA HITECH standards affecting medical records and the impact on reimbursement and accreditation.