Job Description

Employment Type:
Full Time
Other Shift Details:
Job Code:

SDH Coding Specialist II




Performs designated abstracting and coding functions as specified. Assigns diagnostic and procedure codes to outpatient records.

Completes data abstract in 3M for each record coded.

Ensures records are accurately and completely coded according to hospital approved standards. Reports to the Coding Supervisor of Health Information Management (HIM).





Minimum Education

High School Diploma or GED. Registration as Health Information Administrator (RHIA) or Health Information Technician (RHID or certification by the American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC) as a: Certified Coding Specialist (CCS), Certified Professional Coder (CPC) or Professional Coder - Hospital (CPC-H).Must have excellent verbal and written communication skills.Other office skills include daily usage of computers, fax and photocopiers and telephones.


Minimum Work Experience

One or more years of experience in a health related setting. Should be able to concentrate during numerous interruptions Must be able to withstand pressure of scrutiny of work.

Must demonstrate knowledge of ICD-9-CM and/or CPT coding system,3M abstractor/encoder/grouper, MSDRG reimbursement system.

Must possess good verbal and written communication skills and be proficient in English and spelling. Must have good computer skills.

Must be able to work with minimum supervision. Must be able to type and sit for long periods of time. Must maintain professional credentials.




Provides a positive and professional representation of the organization.

Promotes culture of safety for patients and employees through proper identification,reporting, documentation,and prevention.

Maintains hospital standards for a clean and quiet patient environment to maintain a positive patient care experience.




Maintains competency and knowledge of current standards of practice, trends, and developments in related scope of job role or practice.

Adheres to infection-control policies and protocols,medication administration and storage procedures, and controlled substance regulations.

Participates in ongoing quality improvement activities.

Maintains compliance with organization's policies,as well as established practices, protocols, and procedures of the position,department, and applicable professional standards.

Complies with organizational and regulatory polocies for handling confidential patient information.

Demonstrates excellent customer service through his/her attitude and actions,consistent with the standards contained in the Vision,Mission,and Values of the organization.

Adheres to professional standards, hospital policies and procedures,federal,state, anlocal requirements, and TJC standards and/or standards from other accrediting bodies.





Reviews patient's entire medical record and assigns appropriate code.

Determines the sequence of diagnoses according to uniform hospital discharge data.

Reviews all surgical and designated diagnostic procedures and assigns appropriate procedure codes.

Requests diagnoses from physicians when not recorded on discharge, if information is incomplete,or if information is ambiguous.

Abstracts required data items into the medical record abstract system,and ensures data coming from the AS400 is accurate.

Ensures the coding is compliant with CMS, AHA, AMA, DHHS and other governing agency requirements.

Enhances professional growth and development through participation in educational programs, in-services, and workshops and by reading current literature.

Participates in educational programs relatinto job and overall competencies.Attends meetings as required and participates on committees as directed.

Maintains established departmental policies and procedures,objectives,quality assurance, safety, environmental and infection control standards.

Ensures compliance with hospital polocies, procedures,management systems and documentation. Assists in training and orientation of new personnel In coding procedures.

Assists in the care and maintenance of department equipment and supplies.

Maintains a positive environment for the public, patients,hospital personnel,and medical staff by providing an E3 experience.

Performs other duties assigned.





Prolonged periods of standing,walking,or sitting while on duty.

Lifting, pushing,and pulling uto 10-15 pounds with or without assistance.

Visual and auditory acuity and manual dexterity essential to performing designated duties required. Ability to perform effectively in a stressful and fast paced environment.

Ability co pass all required health and other screening tests.




Physical conditions are dean,neat and well lit. Maybe subjected to unpleasant sights and odors, stressful situations and hazardous or infectious agents where judgment as to precautions need to be takeni  essential. Climate control an ambient temperature variances may be experienced.Exposure to limited amounts of hazardous chemicals or substances and infectious disease processes are a possibility. Hours of duty may be

irregular or unexpectedly extended due to emergency circumstances.

Direct contact with blood or other body fluids to which universal precautions apply. Personal protective equipment is made available and must be worn.

Application Instructions

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