Clinical Coding Specialist I – Cape Fear Valley Urology Summary : Reviews thoroughly the entire medical record to code specifically and accurately conditions or diagnoses that were treated or affected the patient's plan of care. Verifies that each medical record contains appropriate documentation to justify the selected principal diagnosis, identifies comorbid conditions, complications, and procedures for DRG assignment, and maintains an accurate case mix index used by administration for critical management and strategic planning decisions. Facility : Cape Fear Valley Urology Location : Fayetteville, North Carolina Department : Cape Fear Valley Urology Job Family : Clerical Work Shift : Days (United States of America) Major Job Functions Codes all diagnoses, treatments, and procedures according to the appropriate classification system for that category of patient encounter. Performs medical record abstracting of hospital admissions for reimbursement and statistical reporting. Verifies patient data while abstracting for accuracy and completeness of patient database. Refers to Local Medical Review Policies, National Determination Coverage Policies and Local Determination Coverage Policies as necessary to ensure compliance with federal guidelines. Assesses OCE, NCCI and CCI edits, as necessary, to apply appropriate modifiers and make appropriate referrals to revenue departments, claim billers, senior coders and other hospital contacts for accurate claim submission. With full understanding of PPS regulations, the DRG classification systems (MS-DRG and APR-DRG), and CMS Patient Safety and Quality initiatives, communicates with physicians regarding the accuracy of principal and secondary diagnoses on the final code set based on lab and other diagnostic findings when the record may be subjected to QIO review due to vague attestation/documentation. Other duties as assigned. Minimum Qualifications Education and Formal Training High school diploma or equivalent required. Associate’s degree preferred. Work Experience Applicants without an Associate degree require 2 years of ICD-CM/CPT‑4 coding experience. Knowledge, Skills, and Abilities Good data entry skills. Familiarity with medical record content and understanding of ICD-CM/CPT‑4 coding principles. Ability to assign accurate codes using good judgment within broad guidelines. Flexible and capable of intense concentration in a busy, noisy and crowded environment. Physical Requirements Near visual acuity. Motor coordination to operate computer. Most work is sedentary. Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity. #J-18808-Ljbffr