Job Description

At ScionHealth , we empower our caregivers to do what they do best. We value every voice by caring deeply for every patient and each other. We show courage by running toward the challenge and we lean into new ideas by embracing curiosity and question asking. Together, we create our culture by living our values in our day-to-day interactions with our patients and teammates.

Job Summary

• Codes medical records, including all diagnoses, operative and diagnostic procedures in patient medical records, using the International Classification of Diseases and enters coded information into an automated system.

Essential Functions

• Using the coding system, assigns and records an accurate code to all diagnoses, procedures, and operations as documented in the patient medical record based on official coding guidelines
• Ensures that all factors necessary for assigning an accurate CPT are present, and that all diagnoses are recorded properly
• Contacts practice designee regarding questions on diagnoses, need for greater detail or different terminology to assign accurate codes to medical records
• Enter final diagnostic codes for diagnoses and procedures
• Complies with internal procedures established to ensure compliance with regulatory agencies
• Reports on potential coding discrepancies to Director of Physician Coding and Director of Physician Auditing & Education to assure that only accurate and properly documented services are coded in accordance with Federal False Claims
• Provides information and responds to inquiries regarding medical documentation and coding questions
• Conducts job responsibilities in accordance with the standards set out in the Company’s Code of Business Conduct, its policies and procedures, the Support Center Compliance Agreement, applicable federal and state laws, and applicable professional standards
• Promotes adherence to the Company’s Code of Business Conduct and the Support Center Compliance Agreement by monitoring employee performance and identifying and responding to compliance issues
• Abstracts and retrieves medical data for evaluation, planning, or research in health care and related programs

Knowledge/Skills/Abilities/Expectations

• Knowledge of medical terminology, International Classification of Diseases (ICD-10-CM) codes, current procedural terminology (CPT) and HCPCS level II codes as appropriate
• Ability to understand and code medical records
• Ability to communicate effectively both orally and in writing
• Exceptional organizational and follow-through skills
• Ability to maintain confidentiality of all patients and/or employee information to assure patient and/or employee rights are protected
• Approximate percentage of time required to travel: 0%
• Must read, write and speak fluent English
• Must have good and regular attendance
• Performs other related duties as assigned
• Sedentary work with extensive use of computers
• Remote work environment with periodic onsite presence at facility or physician practices

Education

• High School or equivalency diploma required
• College degree preferred

Licenses/Certifications

• Current coding certification required (e.g., CPC)

Experience

• 3 years professional coding experience (specialty coding preferred)

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