Facility

Cape Fear Valley Medical Center

Location

Fayetteville, North Carolina

Department

Health Information Management

Job Family

Clerical

Work Shift

Days (United States of America)

Summary

Thoroughly review the entire medical record to code specifically and accurately those conditions or diagnoses that were treated or affected the patient's plan of care. Verify medical records contain appropriate documentation to justify the selected principal diagnosis to identify comorbid conditions, complications and procedures to use for DRG Assignment. Maintain accurate case mix index from which administration makes critical management and strategic planning decisions.

Major Job Functions

The following is a summary of the major essential functions of this job.  The incumbent may perform other duties, both major and minor, that are not mentioned below.  In addition, specific functions may change from time to time:

• Code diagnoses, treatments, and procedures according to the appropriate classification system for that category of patient encounter and in accordance with provisions of the Uniform Hospital Discharge Data Set as well as the interpretation of these provisions as issued by the American Hospital Association and American Health Information Management Association and all governmental and private Third Party rules and regulations

• Perform medical record abstracting of hospital admissions for reimbursement and statistical reporting

• Concurrently code LTAC, Rehab and acute care inpatients based on prescribed requirements by payer, using a computerized encoder and DRG grouper

• Explain to and communicate with physicians regarding the changing of principal diagnoses on the attestation statement, based on lab and other diagnostic findings, when the record may be subjected to PRO review due to vague attestation/documentation

• Assess the adequacy of documentation to ensure it supports the principal diagnosis, principal procedure and complications and comorbid conditions that are coded

• Works with Clinical Documentation Specialists and Reimbursement Specialists to identify areas for improvement in physician documentation

• Assess OCE, NCCI and CCI edits as necessary to apply appropriate modifiers and make appropriate referrals to revenue departments, claim billers, senior coders and other hospital contacts as needed for accurate claim submission

• Analyze clinical findings to determine appropriate secondary diagnoses for patient severity indices

• Use good judgment in determining when to delay billing for obtaining additional documentation to support the assignment of a more optimal DRG

• Make coding supervisor aware of problem issues, negative physician communication and/or other influences that impact effectiveness of job performance

• Other duties as assigned

Minimum Qualifications

The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:

Education and Formal Training: 

• Bachelor's degree in Health Information Management required OR 8 years of equivalent training and experience required

• RHIA, RHIT, CCS or other equivalent credentials required

Work Experience: 

• 5 years coding experience required, preferably in a hospital setting

• 2 years inpatient coding preferred

• 1 year Health Information Management experience in an acute care facility, Peer Review Organization, Quality Assurance, or Utilization Review preferred

Knowledge, Skills, and Abilities Required: 

• Proficiency in reading, writing, and speaking the English language

• Medical terminology, anatomy and physiology, familiarity with medical record content and an understanding of the Uniform Hospital Discharge Data Set (UHDDS) definitions

• Knowledge of ICD-CM coding principles under Prospective Payment System

• Excellent communication skills

• Understanding that decisions are made with very serious impact affecting hospital reimbursement and PRO review determinations

• High degree of interpretation, analysis, planning, coordination, and organization of information

• Decisions require intense mental effort and consideration of reimbursement ramifications

• Ability to utilize experience, practices and organization to accomplish goals

• Ability to assign accurate codes using good judgment in a timely manner within broad guidelines

• Flexible and able to concentrate in a busy, noisy, and crowded environment with demands and interruptions 75% of the time

Physical Requirements: 

• Near visual acuity required

• Motor coordination required to operate computer

• Work requires commuting between nursing units and Medical Record Department

Required Licenses and Certifications

RHIA - American Health Information Management Association

Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity