Job Title

Health Information Management

Job Description

Performs coding and abstracting duties to assure accurate completion of coding for all assigned patient records.

Job Responsibility

1. Analyzes and interprets the medical record in its entirety to ensure accurate, complete and consistent selection of diagnoses and procedures to assure the production of quality healthcare data and accurate facility payment.

2. Applies understanding of basic anatomy and physiology to interpret clinical documentation and identify applicable codes.

3. Utilizes resources and reference materials to identify appropriate codes and reference code applicability, rules and guidelines.

4. Applies the Uniform Hospital Discharge Data Set definitions as well as any additional regulatory guidelines and/or coding references to select the principal diagnosis, secondary diagnoses, all significant procedures, indicating the patient's acuity, sever...