St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.
Codes and abstracts all pertinent patient medical information according to AHA ICD-10-CM/PCS and AMA CPT-4 Coding conventions, UHDDS guidelines and CMS directives. Completes data entry of abstracted inpatient/outpatient diagnosis and/or procedure codes to Network’s health information system. Collaborates with the Health Information/Medical Records, Admissions and Finance departments to ensure appropriate flow of information.
The intent of this job description is to provide a summary of the major duties and responsibilities of this position and shall not be considered as a detailed description of all the work requirements that may be inherent in the position.PLEASE NOTE: A 10-question coding skills assessment is a part of the SLUHN application process. The following materials will be needed in order to complete the assessment: INPATIENT – ICD-10-CM & PCS codebooks; OUTPATIENT – ICD-10-CM and CPT-4 codebooks. Please plan your time accordingly.
JOB DUTIES AND RESPONSIBILITIES:
1. Codes and abstracts diagnosis and procedure information from patient medical records according to AHA ICD-10-CM/PCS and AMA CPT-4 coding conventions, UHDDS and CMS guidelines and regulations. Utilizes the 3M Encoder to verify and assign AHA ICD-10-CM/PCS and AMA CPT-4 codes, and MS-DRG/APR-DRG assignment.
2. Maintains 95% data quality coding accuracy rate as measured through quarterly department quality reviews.
Maintains daily productivity and turnaround times as outlined in Department’s Performance Improvement plan (attachment A)
3. Responsible for remaining up-to-date with knowledge of AHA ICD-9-CM/ICD-10-CM/PCS and AMA CPT-4 coding conventions, MS-DRG and APR-DRG principles and guidelines. Maintains a working knowledge of prospective payment systems as it relates directly to coding process.
Participation in department and sectional meetings, education sessional sessions and workshops as scheduled.
4. Maintains working knowledge of clinical documentation improvement program and functions as liaison for RN clinical documentation specialists (inpatient coding professionals only).
Demonstrates/models the Network’s core values and customer service behaviors and interactions with all customers (internal and external).
5. Maintains confidentiality of all materials handled within the Network/ Entity as well as the proper release of information.
6. Complies with Network and departmental policies regarding issues of employee, patient and environmental safety and follows appropriate reporting requirements.
Demonstrates/models the Network’s Service Excellence Standards of Performance in interactions with all customers (internal and external).
7. Demonstrates Performance Improvement in the following areas as appropriate: Clinical Care/Outcomes, Customer/Service Improvement, Operational System/Process, and Safety.
8. Demonstrates financial responsibility and accountability through the effective and efficient use of resources in daily procedures, processes and practices.
9. Complies with Network and departmental policies regarding attendance and dress code.
1. Assists in training of new personnel
2. Other related duties as assigned.
PHYSICAL/SENSORY DEMANDS: Sitting for up to 7 hours per day, 3 hours at a time. Repetitive arm/finger use retrieving/viewing computerized patient medical record and abstracting of patient information. Extended periods of vision use for reviewing and coding computerized patient records approximately 7 hours per day, 3 hours at a time. Hearing as it relates to normal conversation. Occasionally may be required to use upper extremities to lift up to 10 lbs.; stoop, bend, or reach to retrieve resource materials and/or paper records in accordance with department downtime policy..
POTENTIAL ON-THE-JOB RISKS: No identified risks.
SPECIFIC PROTECTIVE EQUIPMENT AVAILABLE: N/A
MOST COMPLEX DUTY: Ability to apply objective understanding of AHA ICD-10-CM/PCS coding conventions and AMA CPT-4 guidelines. Appropriately assign diagnosis and procedure codes for accurate reimbursement. Understanding computerized health information system and encoding software systems.
SUPERVISION (Received and/or Given): IP and OP coding coordinators
COMMUNICATIONS: Communicate frequently in a tactful, respectful and diplomatic manner with internal and external customers. Advises respective coding coordinators of issues requiring immediate attention.
ADDITIONAL REQUIREMENTS: Expected to maintain designated CEUs for AHIMA credentials (RHIA, RHIT, and/or CCS) in accordance with the AHIMA Governing Body, with confirmation of valid credentials for every two-year cycle reporting. Adherence to the confidentiality guidelines as outlined within the Hospital and departmental policies. Promotes positive customer satisfaction by way of prompt and courteous service.
RHIA, RHIT and/or CCS from an accredited Health Information Technology or Management program.
TRAINING AND EXPERIENCE:
Minimum 1 year demonstrated ICD-10-CM inpatient and/or outpatient coding experience in acute care, teaching setting. Knowledge of anatomy and physiology, pathophysiology, and medical terminology required. Previous experience with EPIC health information computerized patient record and 3M encoding system preferred.
Day shift but may require other hours as necessary.
REVISED: 7/04, 8/11, 2/13, 2/14, 5/16, 1/17
Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!![ Link removed ] - Click here to apply to Certified Coding Specialist[ Link removed ] - Click here to apply to Certified Coding Specialist
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