Employment Status: Full Time
Codingand abstracting of medical and statistical information from the medical recordfor billing and statistical purposes on a concurrent and post discharge basis.Assignment of appropriate MS-DRGs to Medicare and all non-Medicare payors asneeded. Assignment of appropriate ICD-9-CM/ICD-10 codes and MS-DRGs forinpatient admissions stays. Promotes ongoing team collaboration betweenconcurrent (CDI) clinical documentation improvement specialists, physicians andother clinicians to improve clinical documentation for the hospital
ESSENTIAL DUTIES AND RESPONSIBILITIES:
1 Provides concurrent coding as needed on dailyadmits.
2.Accurately codes and sequences all diseases and procedures found in the medicalrecord using ICD-9-CM/ICD-10 coding systems.
3.Accuratelyassigns the Present on Admission (POA) indicator to every principal andsecondary diagnosis on all inpatient encounters.
4.Assignsappropriate MS-DRG to Medicare and non-Medicare patients.
5.Keepscurrent with ongoing coding changes.
6.Abstractsinformation from the medical record for statistical purposes.
7.Regularlyworks on the DNFB (Unbilled) Pending List & any other reports as needed.
8.Keepsa daily record of productivity.
9.Assistsphysician office staff and other intra-hospital departments with codingquestions.
10.Assistswith special research projects for physicians.
11.Responsiblefor maintaining a working knowledge of Medicare rules and regulations.
12.Demonstratesa thorough knowledge of medical terminology.
13.Understandsand applies appropriate coding guidelines.
14.Exhibitsthe ability to research topics if needed.
15.Understandsthe purpose of coding and its impact to reimbursement
1.Knowledgeof Diagnostic Related Groups (DRGs) is required.
2.Experiencein abstracting requested but not required.
3.Knowledgeof ICD preferred.
4.Workingknowledge of Joint Commission and OIG guidelines preferred.
Requiredgraduate from an approved Health Information Management Program withcredentials of Registered Health Information Administrator (RHIA) or RegisteredHealth Information Technician (RHIT) and/orCCS, LPN, RN or B.S. in a medical related field. A minimum of 1 year ofinpatient coding experience is required using the ICD-9-CM/ICD-10 codingsystems. Promotions from within from outpatient coder to inpatient coder willbe considered at the discretion of the Coding Supervisor dependent onindividual coder knowledge, accuracy, years of experience, and passing score oncompany-administered inpatient coding quiz.
PHYSICALDEMANDS AND WORKING CONDITIONS:
• Medium Work asdefined by the U.S. Department of Labor constitutes a maximum lift of 21-50pounds on occasion and/or a maximum lift of 11-25 pounds on a frequent basis
• May be required to assist in the turning, lifting, or movingpatients as well as walking about from patients’ rooms, aswell as to and from various hospital areas
Formal application;verification of education, and experience; verification of license(s),certification(s), registration(s), accreditation(s) if applicable; oralinterview, reference and background checks; job related tests may be required.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skills, and abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Must comply with all SERVICE Standards of Behavior