Job Description

General Summary of Position
The Outpatient Coding Specialist II analyzes and interprets clinical documentation to accurately code and abstract primarily Ambulatory Surgery records and other outpatient records for all MedStar entities in accordance with established ICD-10-CM/PCS CPT and other applicable coding classification schemes.

Primary Duties and Responsibilities

• Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations.
• Abstracts and ensures accuracy of diagnoses procedure patient demographics and other required data elements.
• Adheres to all compliance regulations and maintains annual compliance education.
• Maintains continuing education and seeks ongoing education to improve job performance. Maintains credentials as required for job classification.
• Contacts physician when conflicting or ambiguous information appears in the medical record. Adheres to the MedStar Coding Query Policy and procedure.
• Consistently meets or exceeds established Quality standards as defined by policies.
• Consistently meets or exceeds established Productivity standards as defined by policies.
• Resolves all quality reviews timely (e.g. Medical necessity reviews; Coding Quality assurance reviews; external vendor reviews).
• Reviews medical record documentation to identify diagnoses and procedures. Assigns correct diagnostic procedural codes and appropriate modifiers using standard guidelines and automated encoding software maintaining departmental accuracy standards.
• Exhibits knowledge of the Solventum system and other work-related equipment.
• Participates in meetings and on committees and represents the department and hospital in community outreach efforts.
• Participates in multi-disciplinary quality and service improvement teams.
• Performs other duties as assigned.

Minimal Qualifications
Education

• High School Diploma or GED required
• Associate's degree preferred 
• Bachelor's degree in coding related degree preferred
• Courses in Medical Terminology Anatomy & Physiology ICD-CM and CPT-4 required

Experience

• 2 years ASU (Ambulatory Surgery) coding experience and experience with clinical information systems (Solventum grouper electronic medical records computer assisted coding) required

Licenses and Certifications

• CCS (Certified Coding Specialist) CCS-P (Certified Coding Specialist-Physician-based) required
• COC (Certified Outpatient Coder) required and
• RHIT (Registered Health Information Technician) preferred
• RHIA (Registered Health Information Administrator) preferred

Knowledge Skills and Abilities

• Verbal and written communication skills.
• Basic computer skills required.
• Strong analytical and organizational skills; ability to prioritize workloads and meet deadlines.

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