HIM Coder (Per Diem)

Position: Inpatient Medical Coder II

Department: Clinical Documentation

Schedule: Per Diem

Location: Remote

ESSENTIAL DUTIES & RESPONSIBLITIES:

Assigns appropriate codes to reflect  all diagnoses and procedures extrapolated from physician and appropriate provider documentation during a patient encounter according to the most current coding methodologies, including ICD-10-CM and ICD-10-PCS resulting in appropriate reimbursement. Abstracts required data to input into the Medical Center's computerized data base.   Converts all patient visits and encounters into appropriate DRG (Diagnosis-related group) MSDRG, APR DRG assignments in order to correctly submit the optimal reimbursement for each patient encounter coded.

Abiding by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adhering to official coding guidelines and departmental procedures, the Medical Coder:

• Reviews patient medical records and abstracts medical data that identifies all diagnoses and procedures.  Codes diagnoses, procedures, and appropriate modifiers from the medical record documentation using ICD-10-CM/PCS, CPT4/HCPCS classification systems.  Refers to a computerized encoding system, written coding aids and other reference materials to ensure accurate coding for billing. 

• Sequences diagnoses, procedures and complications by following ICD-10-CM/PCS, CPT-4, the Uniform Hospital Discharge Data Set (UHDDS); adheres to the Official Guidelines for Coding and Reporting, Coding Clinic guidelines and other regulatory guidelines as appropriate. Consults with the CDCI team to request appropriate physician or appropriate medical staff to clarify medical record information.

• Assigns grouper codes to each record according to patient type and financial class (DRG, ASC, APG, etc.).  Enters coded/abstracted information in grouper, analyzes groupings, and assigns the appropriate grouper for appropriate and accurate reimbursement.  Data enters abstracted information into the Medical Center's computerized database.

• Assists the clinical documentation specialists in medical record documentation auditing as needed.

• Maintains accuracy rate of 95% or better.

• Maintains productivity standards set forth in Departmental Policies and procedures. 

• Contacts Medical Records departments to track missing records so that all records can be billed.

• Maintains professional skills and knowledge of coding through attendance at in-service programs, conferences, workshops and other educational programs and review of current literature. Assist in training new personnel in department coding procedures.

• Utilizes hospital’s behavioral standards as the basis for decision making and to facilitate the hospital’s goals and mission.

• Follows established Hospital infection control and safety procedures.

• Performs other duties as needed.

JOB REQUIREMENTS

EDUCATION:

• Level of knowledge equivalent to that ordinarily acquired through completion of an Associate's Degree in Health Information, Medical Records or similar program. An equivalent combination of education and experience, which provides proficiency in the areas of responsibility, may be substituted for the stated education and experience requirements.

EXPERIENCE:

• 3 years inpatient coding experience in a Level 1 Trauma, Teaching Facility

CERTIFICATIONS, LICENSURES, & REGISTRATIONS:

• Preferred: Certified Coding Specialist

• Requires inpatient CCS, RHIT or RHIA credentials from AHIMA

• CCS coding credential requires inpatient coding experience before taking exam RHIT and RHIA must have associate’s and bachelor’s degree respectively before taking exam

KNOWLEDGE AND SKILLS:

• Work requires in-depth knowledge of medical terminology, ICD-10-CM/PCS and CPT-4 Coding conventions and knowledge of the various DRG systems (CMS DRGs, AP-DRG, and APR-DRGs). 

• Work also requires basic concepts of human anatomy, physiology and pathology.

• Experience with ICD-10-CM/PCS for diagnoses and procedures.

• Strong knowledge of health records, computer systems, Microsoft applications, data integrity, and processing techniques required.

• Excellent organizational skills, including ability to multi-task, prioritize essential tasks, follow-through and meet timelines.

• Ability to work with accuracy and attention to detail.

• Ability to solve problems appropriately using job knowledge and current policies/procedures.

• Ability to work cooperatively with members of the healthcare delivery team and staff, ability to handle frequent interruptions and adapt to changes in workload and work schedule and to respond quickly to urgent requests.

• Must be able to maintain strict confidentiality of all personal/health sensitive information and ensure compliance of HIPAA rules and regulations.