**Description** Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines. Today at Penn Medicine, someone will make a breakthrough. Someone will heal a heart, deliver hopeful news, and give comfort and reassurance. Our employees shape our future each day. Are you living your life's work? Summary: + Position Summary: : Codes and abstracts information from inpatient and outpatient records by careful analysis and adherence to official coding guidelines assuring appropriate reimbursement, compliance with regulations, and accuracy for clinical care analysis and provider profiling. Review coded medical records for coding and DRG accuracy by verifying that the principal diagnosis, secondary diagnoses, principal procedure, and secondary procedures have been assigned accurately and produce the highest level of reimbursement to which the facility is legally entitled. This shall be completed according to established coding guidelines and rules for reporting. + Qualified individuals must have the ability with or without reasonable accommodation to perform the following duties: + Demonstrates commitment to the Standards of Ethical Coding as set forth by the American Health Information Management Association AHIMA . Assigns codes based upon clinical coding guidelines. + Perform SMART audits on 100% flagged records. Perform focused audits as necessary. Perform disposition code assignment audits. + Perform post discharge physician queries to assist in clarifying vague or unclear documentation. Keep data on query response rate. + Provide SMART tool training to new coding staff and cross training to existing staff as needed. + Research, review and respond to coding and coding quality issues and questions from various internal and external departments, in coordination with Clinical Coding Trainer and or CDI Coding Liaison. + Refer coding classification, HDM, and severity of illness assessment questions to management in a timely manner for determination and guideline development. + Communicate with co-workers, management, physicians, and other hospital staff regarding clinical documentation and reimbursement issues. + Summarize and report quality results and trending issues on a weekly basis during SMART workgroup meeting to Trainer, Supervisor and Liaison. + Perform audits of the assigned ICD-10-CM and PCS codes to insure that charts are coded by adhering to coding conventions and official coding guidelines with 95% accuracy. + Perform audits of the assigned DRGs to insure accurate, optimal assignment with 95% accuracy. Simultaneously review the accuracy of all abstracted data to insure key elements are abstracted correctly. + Identify and communicate documentation issues and concerns that influence coding, DRG assignment, and severity of illness assessment to management as identified. + Perform account completion activities i.e. verify disposition, contacting providers for OP notes, answering coder questions, Query completion, missing documentation as needed to positively impact DNB. + Assist with the weekly monitoring of WQ process and maintenance of the IP DNB. + Participate in the development of institutional and organizational coding policies. + Assigns ICD-10-CM diagnostic, procedure codes with appropriate present on admission indicators to inpatient records, based upon the practitioner clinical documentation. Determines appropriate MS-Diagnostic Related Group DRG based upon diagnoses and procedure codes assigned. + Assigns ICD-10-CM diagnostic and CPT procedure codes and modifiers to outpatient accounts. + Abstracts required clinical and demographic data from inpatient and outpatient records. + The following duties are considered secondary to the primary duties listed above: + Assists Patient Financial Services and physician offices with coding—related issues. + Completes a productivity record on a daily basis and submits to Clinical Coding Supervisor weekly. + Assists with appropriate capture of inpatient case mix. Responsibilities: Minimum Required Qualifications: + High school diploma or equivalent GED . + Formal education in ICD-10-CM PCS and CPT-4 coding, medical terminology, anatomy and physiology. + Three 3 to five 5 years’ experience in ICD-10-CM and ICD-10-PCS coding principles guidelines. + Three 3 to five 5 years’ experience in MS-DRG assignment analysis and or CPT coding principles guidelines. + Certification as a Certified Coding Specialist CCS or Certified Coding Specialist-Physician CCS-P through AHIMA American Health Information Association , or certified by AAPC American Association Professional Coders with certification as a Certified Professional Coder CPC , or Certified Professional Coder-Hospital Outpatient COC .Must meet one of the following criteria: + Certified Coding Specialist CCS and or AAPC Certifications CPC, COC . + Bachelor of Science degree in Health Information Management with certification as a Registered Health Information Administrator RHIA . + Associate of Science degree in Health Information Technology with certification as Registered Health Information Technician RHIT by the American Health Information Management Association AHIMA .Preferred Qualifications: + Must demonstrate experience with encoding software. + Must demonstrate extensive knowledge of coding, sequencing, and documentation guidelines. + Must have strong quantitative and analytical skills. + Must have experience in ICD-10 CM PCS and CPT HCPCS, Inpatient coding. + Demonstrates proficient computer skills and Microsoft Office. We believe that the best care for our patients starts with the best care for our employees. Our employee benefits programs help our employees get healthy and stay healthy. We offer a comprehensive compensation and benefits program that includes one of the finest prepaid tuition assistance programs in the region. Penn Medicine employees are actively engaged and committed to our mission. Together we will continue to make medical advances that help people live longer, healthier lives. Live Your Life's Work We are an Equal Opportunity employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law. REQNUMBER: 274520