General Summary: Under moderate direction, reviews and interprets medical record documentation, assigns diagnostic and/or procedural codes, and abstracts case information for reimbursement, research, and planning purposes. Ensures that all codes assigned are supported by sufficient documentation, and are based on official coding and reporting guidelines. Interacts with medical staff, Clinical Documentation Improvement specialists, and other hospital departments to improve the quality of documentation, and ensures documentation accurately reflects severity of illness and intensity of service for each patient.
Essential Duties:
1.Reviews and interprets medical record documentation for either concurrent or discharged cases, and assigns accurate ICD-10 and CPT codes in accordance with coding guidelines and regulatory requirements to ensure appropriate reimbursement for services provided.
2. Accurately abstracts medical record information for reimbursement, research, and planning purposes.
3. Creates meaningful, compliant queries to physicians for clarification of inconsistent, ambiguous, or nonspecific medical record documentation.
4. Attends meetings with physicians and other clinical staff as requested.
5. Assists and educates physicians and other clinicians on proper documentation practices.
6. Serves as a resource for coding related issues.
Standard Qualifications:
Associates or bachelor's degree in health information management.
ICD-10 and/or CPT coding experience preferred.
RHIA, RHIT, or RHIT eligible - must obtain the accreditation within six months of employment.
Beaumont Health is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, gender identity, sexual orientation, age, status as a protected veteran, or status as a qualified individual with a disability.
