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Health information coding is the transformation of verbal descriptions of diseases, injuries, and procedures into numeric or alphanumeric designations. The coding process reviews and analyzes health records to identify relevant diagnoses and procedures for distinct patient encounters. Coders are responsible for translating diagnostic and procedural phrases utilized by healthcare providers into coded form procedure codes that can be utilized for submitting claims to payers for reimbursement. A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.
Reviews the content of the medical records from multiple EHR's and on-site for both hospital and professional inpatient or outpatient records to identify principal diagnosis, secondary diagnoses and procedures performed.
Carefully reviews details of documents such as laboratory findings, radiology reports, various scan reports, discharge summary, history and physical, consultations, orders, progress notes and other ancillary services treatment records needed to ensure all pertinent diagnoses and procedures are recorded.
Failure to properly identify diagnoses and procedures may have a dramatic negative impact upon payment received by The Health Plan.
Assigns codes based on hospital and professional coding guidelines, Coding Clinic directives, federal regulations, CCI coding initiatives, CPT Assistant or other standard coding guidelines.
Provides material to the RACE team to educate physicians as needed to clarify documentation within the patient's record to facilitate complete and accurate coding.
Assists in decision making relevant to physician coding education and HCC targeting purposes.
Provides encoder software and EMR (EPIC) expertise and uses these tools along with their knowledge in the anatomy and physiology of the human body and disease processes in order to understand the etiology, pathology, symptoms, signs, diagnostic studies, treatment modalities, and prognosis of diseases and procedures to be coded.
Ensures strict confidentiality of financial and medical records.
Develops and maintains expertise in non-EPIC EMR systems as deemed appropriate by the Chart Retrieval team.
Updates and corrects historical file data by submitting delete files and notifying the RACE team.
Work is typically performed in an office environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.
High School Diploma or Equivalent (GED)- (Required)
Minimum of 5 years-Relevant experience* (Required)
Certification(s) and License(s)
Certified Professional Coder - American Academy of Professional Coders (AAPC); Certified Risk Adjustment Coder - American Academy of Professional Coders (AAPC); Registered Health Information Technician (RHIT) - American Health Information Management Association
We are an Affirmative Action, Equal Opportunity Employer Women and Minorities are Encouraged to Apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
At Geisinger, our innovative ideas are inspired by the communities we serve – like our Fresh Food
Farmacy, a program that delivers life-saving healthy alternatives to patients with diabetes. With additional tools like our MyCode Community Health Initiative, one of the first health system genome sequencing
programs, and our new asthma app suite that we developed in partnership with AstraZeneca, it’s no wonder we’re ranked one of the Top 5 Most Innovative Healthcare Systems by Becker's Hospital Review. We continually work towards continuous improvement in a culture where everyone has a voice and firmly believe that better begins with all of us.
Founded more than 100 years ago, Geisinger serves more than three million residents throughout central, south-central and northeastern Pennsylvania and southern New Jersey. Our physician-led system is comprised of 30,000 employees, including 1,600 employed physicians, and consists of 13 hospital campuses, the Geisinger Health Plan, Geisinger Commonwealth School of Medicine and two research centers.
What you do at Geisinger shapes the future of health and improves lives – for our patients, communities, and you.