General Summary Collects, reviews, retrieves and codes data by careful review and analysis of documentation of inpatient medical records, assigning the appropriate ICD-10 codes for the purposes of compliance with regulations, statistical compilation, clinical research, clinical care analysis, provider profiling and optimal reimbursement. Duties and Responsibilities Essential Functions: • Reviews entire current electronic medical record for pertinent diagnoses and procedures. • Assigns diagnoses and procedure codes on inpatient records in accordance with established organization guidelines. • Uses ICD-10 CM and PCS coding methodologies following Official Guidelines for Coding and Reporting using encoding software. • Queries physicians to clarify documentation needed for coding purposes per established departmental policy. • Performs abstraction of clinical and demographic data as pertinent to the account requirements. • Participates in documentation improvement program using 3M software and communicating with Clinical Documentation Specialist regarding DRG assignment. • Performs other duties that may be assigned by authorized personnel or as required to meet emergency needs of the department or Hospital. Common Expectations: • Maintains job specific standards and expectations relative to productivity and quality. • Maintains established policies and procedures, objectives, quality assessment and safety standards. • Participates in educational programs and in-service meetings. • Maintains professional growth and development and professional credentials. • Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation. Qualifications Minimum Education: • High School Diploma or GED Required • Associates Degree Preferred or • Bachelors Degree Preferred Work Experience: • 3 years medical coding Required • 3 years inpatient coding Preferred Licenses: • Certified Professional Coder Upon Hire Required or • Certified Coding Associate Upon Hire Required or • Certified Coding Specialist Upon Hire Required or • Registered Health Information Technician Upon Hire Required or • Registered Health Information Administrator Upon Hire Required or • Certified Professional Coder Apprentice Upon Hire Required Knowledge, Skills, and Abilities: • Knowledge of ICD-10 • Knowledge of medical terminology, anatomy, and physiology • Basic computer skills Benefits Offered: • Comprehensive health benefits • Retirement savings plan • Paid time off (PTO) • Education assistance • Financial education and support, including DailyPay • Expanded Paid Parental Leave For additional details: Benefits & Incentives | WellSpan Careers (joinwellspan.org)