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 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 when coding with accuracy and completeness as supported by documentation.
• Ensure accurate coding by clarifying diagnosis and procedural information through a query process.
• Assign Present on Admission (POA) value for inpatient diagnoses.
• Ensure accurate physician name against each service and accurate time...