The HIM Coding Specialist I is required to have a full understanding and active participation in fulfilling the mission, vision and values of San Gabriel Valley Medical Center. The employee shall support San Gabriel Valley Medical Center’s strategic plan and the goals and direction of the department Performance Improvement Plan (PIP).

The HIM Coding Specialist I is required to ensure that all patient records are coded within the bill-hold limits (4 days). HIM Coding Specialist I is further responsible to ensure that all charts pass the SMART cycle and are adjusted as needed. The HIM Coding Specialist I must have a comprehensive knowledge of ICD-10-CM, ICD-10 PCS, CPT conventions in accordance with Official Guidelines for Coding and Reporting. The HIM Coding Specialist I is responsible for abstracting data into Evident/Thrive system using 3M encoder. Furthermore, the HIM Coding Specialist I will work internally and externally with coding staff, HIM director and outside auditors and consultants to ensure the efficiency and quality of coding. The HIM Coding Specialist I must at all times safeguard and protect the patient’s right to privacy by ensuring that only authorized individuals have access to the patient’s medical information and that all releases of information are in compliance with the request, authorization, company policy and HIPAA regulations.

The HIM Coding Specialist I job summary includes but is not limited to:
Assign and sequence ICD-10-CM, ICD-10-PCS and CPT codes for all specialty patient types which may include outpatient, ambulatory surgery, and emergency room records
Accurately code outpatient referred cases and ancillary visits (25 encounters per hour)
Accurately code outpatient ambulatory records (3 encounters per hour)
Accurately code and abstract Emergency Department records (7 per hour, including E&M level and injections and infusions)
Accurately code Obstetrical and Neonatal records (5 per hour)
Maintain coding accuracy performance above 95 percent by appropriately assigning ICD-10-CM and CPT codes according to guidelines
Abstract clinical data, including discharge disposition, accurately after documentation assessment
Query physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes
Select and assign revenue codes based on CPT codes, where appropriate
Perform medical record review for the timeliness and completeness of clinical documentation
Participates in continuing education activities to enhance knowledge, skills and keep credentials current

Knowledge of ICD-10-CM/PCS Official Guidelines for Coding and Reporting

Knowledge of AHA Coding Clinic for ICD-10-CM/PCS

Knowledge of AHA Coding Clinic for HCPCS

Knowledge of HIPAA regulations and to complete work in compliance of these and other standards

Ability to read and comprehend advanced medical terminology

Effective verbal and written communication skills

Effective organizational skills 

Ability to use fax, copier, scanner and multiline phone system and other required work tools

Ability to learn new equipment, systems and required processes in a fast paced environment

Ability to work professionally, effectively, and efficiently in a team environment with customers, management and co-workers

Education/Training/Experience

• High School Diploma or equivalent
• Certified Coding Specialist credentials from AHIMA required
• Minimum of an Associates’ Degree in healthcare related discipline desired
• Minimum of two years coding experience in a hospital Health Information Management Department (may be substituted for credentials)
• Advanced computer skills including keyboarding and Microsoft desktop applications (Word, Excel, Outlook)

Licenses/Certifications

• Certified Coding Specialist (CCS) or RHIT/RHIA credentials from AHIMA