Description Position Summary Responsible for accurately and timely coding of low to moderate complexity community or tertiary outpatient or inpatient encounters independently following established coding, CMS regulations and hospital guidelines. Accurately codes diagnostic and procedural information following official coding guidelines, facility specific guidelines and federal regulations. Essential Functions Reviews complex medical records to identify sequence, code diagnoses and procedures according to established coding, CMS and hospital guidelines. Responsible for accurately coding outpatient ambulatory surgery, observations, ancillary services, select professional, ED and inpatient encounters. Ensures optimal CPT, ASC, APC, APG, DRG, SOI and ROM assignment as applicable. Understanding of CCs/MCCs, impact on quality reporting, UHDDS guidelines, HACs and PSIs. Follows facility query policy and CDI reconciliation process. Supports OP Clinical Documentation Improvement program. Maintains productivity and quality rate according to established standards. Works within UH Billing time frames. Maintains coding knowledge and skills via written coding resources, clinical information and educational webinars. Maintains knowledge of guidelines and regulations affecting the UHHS Coding Department. Maintains up to date credentials. Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA). Additional Responsibilities Participates in educational and informational activities as required. Required For All Jobs Performs other duties as assigned. Complies with all policies and standards. For specific duties and responsibilities, refer to documentation provided by the department during orientation. Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace. Equal Opportunity Employer -- minorities/females/veterans/individuals with disabilities/sexual orientation/gender identity