Job Description

• Review inpatient clinical information, diagnostic terms, and procedural descriptions, and assign accurate numeric codes for each diagnosis and procedure using official ICD-10-AM/ACHI/ACS guidelines. Apply knowledge of medical terminology, disease processes, and pharmacology.
• Complete clinical abstract (computerized file) that summarizes the following patient information: demographics, admission diagnosis, final diagnoses, procedures, physician information, and other information as deemed pertinent by the facility.
• Utilize technical coding principles and AR-DRG reimbursement expertise to assign appropriate ICD-10- AM/ACHI/ACS diagnoses and procedures.
• Perform data quality reviews on patient records to validate ICD-10-AM/ACHI/ACS code assignment, appropriateness, and missed secondary diagnoses and procedures, and ensure compliance with the Health Information Management (HIM) coding guidelines. Demonstrate tested data quality and integrity skills.
• Continuously evaluate the quality of clinical documentation to spot incomplete or inconsistent documentation for inpatient encounters that impact the code selection. Bring identified concerns to physicians/residents/supervisors for diagnosis/procedural clarification.
• Participate in training of facility healthcare professionals in use of coding guidelines and practices, proper documentation techniques, medical terminology, and disease processes appropriate to the job description and functions as they relate to clinical data quality management. Maintain knowledge of current professional coding certification requirements and be responsible for certification maintenance.
• Abide by the Standard of Ethical Coding as set forth by the Australian Health Information Management Association (HIMAA) and adhere to official Australian Coding Standards.
• Keep abreast of new technology in coding and abstracting software and other forms of automation and issues that impact coding functions.
• Demonstrate competency in the use of computer applications and all coding and abstracting software and hardware currently used within the organization.
• Participate in quarterly coding evaluation to identify volume, accuracy, and additional training needs as identified.
• Provide reports on a regular basis and as directed by the respective supervisor of the operations and progress of the data management processes.

Perform other job-related duties as required.