Medical Records Coding Analyst

Madonna Rehabilitation Hospital


At Madonna, we combine heartfelt hospitality with incomparable innovation and education. Our clinical expertise, world-class research and state of the art equipment empower us to help all patients, even those whose diagnoses pose the most complex challenges. Our investment in the exceptional talent, groundbreaking technology and progressive treatments is changing the face of rehabilitation!

Other hospitals treat patients, we change lives! Madonna Miracles and breakthrough moments happen every day; when patients who could not previously walk or speak independently, joyfully celebrate when they hear: “Now You Can!”

We are excited about the opportunity to partner with individuals who wish to enter health care! Now is the opportunity to be a part of something meaningful!

Job Description:

The Medical Records Coding Analyst is responsible for the hospital inpatient and outpatient ICD-10-CM and ICD-10-PCS coding and DRG functions. Applies appropriate diagnostic and procedural codes to individual patient health information for data retrieval, analysis and reimbursement of claims. Analyzes inpatient and outpatient medical records including laboratory and radiology requisitions and assigns codes for diagnoses, procedures and symptoms using a nationally recognized coding system, ICD-10-CM and ICD-10-PCS. Serves as a liaison between case managers, physicians, and therapists to clarify documentation to achieve accurate coding. Responsible for knowing Medicare and Medicaid regulations, as well as other payer requirements, regarding coding and documentation. Must be able to maintain strict confidentiality. Responsible for quality service delivery and internal/external customer relations for the department and Madonna as a whole, including the mission and values for the department and facility and/or system.

Essential Functions:

  • Reviews, interprets, assigns, and verifies ICD-10-CM diagnosis and ICD-10-PCS procedure codes for all inpatient and outpatient diagnoses and procedures.
  • Utilizes an encoder to help ensure accurate and consistent code and DRG assignment, using all available references, edits and customized tips.
  • Interprets clinical documentation using knowledge of anatomy, physiology, disease process and medical terminology.
  • Maintains disease and procedure indexes on all inpatients and outpatients by entering ICD-10-CM and ICD-10-PCS codes into the abstracting system.
  • Contributes to the completion of the Inpatient Rehabilitation Facility – Patient Assessment Instrument by selecting and entering assigned data fields.
  • Verifies that all medical records of admitted inpatients and registered outpatients are coded and abstracted.
  • Assigns ICD-10-CM codes to symptoms and/or diagnoses from all laboratory and radiology requisitions and enters ICD-10-CM codes in abstracting system where appropriate.
  • Reviews medical records concurrently and/or retrospectively and adds diagnosis and procedure codes to capture a complete picture of the patient’s condition during their stay at Madonna.
  • Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines; Revises Madonna Rehabilitation Hospital Coding Guidelines as necessary to remain current and consistent with official coding guidelines.
  • Keeps abreast of coding guidelines and reimbursement reporting requirements. Brings identified concerns to immediate supervisor or department manager for resolution.
  • Completes continuing education to obtain/maintain coding certification status.
  • Assists with data collection and report completion for DRG analysis and qualifying diagnoses analysis.
  • Assists with preparation of medical records for review by: 1) MRH supervisors, managers and committees; 2) MRH employees conducting quality assurance studies and research; 3)the Quality Improvement Organization; 4)external accrediting/licensing agencies (NDHHS, CARF, The Joint Commission etc.); 5) external financial auditing organizations; 6) any other legitimate request.
  • Assists with filing loose documentation in the appropriate medical record.


  • Communicates with appropriate individuals regarding the results of documentation and coding quality reviews, including physician and therapist queries when code assignments are not straightforward or documentation in the record is inadequate, ambiguous or unclear for coding purposes; must be diplomatic and persuasive in presenting the expectation of timely, concise, thorough documentation of diagnoses and/or symptoms to support services rendered.
  • Communicates with appropriate individuals regarding the results of other reviews including external providers of service; must be diplomatic and persuasive in presenting the expectation of good patient record documentation for compliance, customer satisfaction and revenue generation.
  • Identifies learning opportunities and provides education to case managers, physicians and other clinicians based on coding and documentation reviews.
  • Provides access to medical records to authorized individuals.
  • Answers questions about the medical record content or patient stays at Madonna to authorized internal and external customers.
  • Takes instruction from immediate supervisor to perform other functions as assigned in order to achieve the goals within the department.


  • Operates PC and software to review and/or enter master patient index information, diagnoses and procedure codes and clinical documentation.
  • Operates PC and encoder software to find and select appropriate diagnosis and procedure codes.
  • Operates fax machine in order to request and receive clinical documentation from external sources, as well as scan documents to appropriate internal customers.
  • Maintains and assures a safe environment for the department. Handles and operates all necessary equipment and performs required duties according to established safety standards to maintain compliance with regulations and prevent injury.

Physical Demands and Environmental Conditions:

  • Sedentary work – lifting 25-30 pounds occasionally or lifting and carrying 25-30 pounds occasionally.
  • Indoor work – not exposed to outside elements or hazard.
  • Near acuity and accommodation are required for reviewing the medical records and assigning ICD-10-CM codes.
  • Reaching, handling, and fingering and/or feeling are required for keyboard and mouse entry.
  • Requires sufficient sight to see and read reports and computer screen. Requires sufficient hearing and speaking to communicate by phone or in person.

 Required Qualifications:

  • Experience – Preferred – One year ICD-10-CM coding experience with inpatient or outpatient records preferred.
  • Credential – CCS certification preferred. Ability to obtain the CCS credential within 18 months of hire.
  • Skills – Required
  • Extensive knowledge of medical terminology, anatomy and physiology, disease pathology and coding principles. Attention to detail. Knowledge of Medicare and Medicaid regulations and resources. Must have excellent reading, grammar, and organizational skills.

Education Qualifications:

Advanced education with eligibility for coding certification from an AHIMA approved program.
(CCS eligible).

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