Responsible for abstracting and analyzing clinical information from medical records and relevant documents, translating the information into diagnostic and operative procedure codes in accordance with the clinical coding system.

Responsibilities

• Assign codes for diagnoses, treatments, and procedures according to the appropriate classification system for outpatient (OP), emergency department (ED), or observation short stay.
• Oversee and review provider documentation to determine principal diagnosis, comorbidities and complications, secondary conditions, and surgical procedures.
• Adhere to official coding guidelines to ensure accuracy and completeness as supported by documentation.
• Clarify diagnosis and procedural information through a query process to ensure accurate coding.
• Assign Present on Admission (POA) value for inpatient diagnoses.
• Ensure accurate physician name for each service and accurate time and da...