Responsible for the coding of diagnoses and procedures on ER medical records.

FUNCTIONAL DEMANDS

Reports to:

Coding Manager and/or HIM Director

Inclement Weather:

Non-essential

Organizational Expectations

·          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 policies 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, and local requirements, and TJC standards and/or standards from other accrediting bodies.

·          As a Studer Partner must have the ability to develop a full understanding of the Studer Group practices and tools and communicate effectively. Must embrace the Studer Philosophy and Principals by conducting him/herself in a professional manner.

Will be held accountable to the following Studer Philosophies and Principles:

•  HCAPS Patient Perception

•  Hourly Rounding with intention

•  Bedside Shift Report

•  AIDET

•  Daily Huddles

NONESSENTIAL FUNCTIONS

Demonstrates ability to be flexible and completes all other duties as needed by Coding Data Quality Manager or Director of Health Information Management.

Other duties as assigned.

ESSENTIAL FUNCTIONS

·          Accurately and completely codes all inpatient records, to ensure assigned codes conform to current coding conventions, achieving 95% accuracy in code assignment.

·          Accurately and completely codes all outpatient record types assigned by Manager to ensure assigned codes conform to current coding conventions, achieving 95% accuracy in code assignment.

·          Calculates the observation hours when coding Observation accounts. Provides notification to assigned point of contact in Patient Financial Services for the observation hours that are required to be backed out of the observation hours that are billed.

·          Performs coding consistent with productivity benchmarks.

·          Consults providers for clarifications and additional documentation prior to code assignment when there is conflicting or ambiguous data in the health record.

·          Demonstrates competency in analyzing grouper changes, weight recalibrations, ICD-10-CM and ICD-10-PCS changes and UHDDS reporting requirements.

·          Demonstrates an understanding of other payment methodologies that use clinical data such as Ambulatory Surgery Center (ASC) payment groups, Ambulatory Payment Groups (APG) and Resource Based Relative Value Scale (RBRVS)

·          Reviews Peer Review Organization notices for DRG changes and admission denials.

·          Performs weekly review of Un-Coded accounts for missed accounts and codes those noted if necessary documentation is present.

Minimum Education

High School graduate or GED equivalent.  CCS or CPC required.  Associates in Health Information Management (or similar program) from an accredited program, preferred.

Minimum Work Experience

Medical terminology and anatomy and physiology required. Minimum of two (2) years' experience in acute care hospital based ICD-10-CM and ICD-10-PCS coding required. Experience with CPT-4 coding desirable. Working knowledge of AHA Coding Clinics and Local Coverage Determination Policies.

Required Skills

Proficient in ICD-10-CM, ICD-10-PCS coding and DRG optimization; experienced with electronic medical record. Exceptional communication (verbal and written) and interpersonal communication skills; ability to interact with all levels of the organization effectively; possess high level of organization and ability to work both independently and with members of Medical Staff, Clinical Documentation Improvement Specialists, and other hospital staff.

Required Certifications

CCS or CPC certification required.  RHIT - new grads considered (must obtain certification within 18 months of hire.