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- Pasadena, CA
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HIM HOSPITAL CODER II - OFFSITE
The Judge Group • Pasadena, CA
Posted 1 month ago
This job will have the following responsibilities:
Review medical records to identify diagnoses/procedures. Independently organizes and prioritizes all work to ensure that records are coded in timeframes that will assure compliance with regulatory requirements.
- Demonstrates a comprehensive, expert-level of knowledge of all procedures concerning the sequencing of diagnoses, procedures such as but not limited to those outlined in ICD-10-CM, CPT, Uniform Hospital Discharge Data Set, Medicare guidelines and other appropriate classification systems.
- Demonstrates knowledge of anatomy and physiology to interpret general medical classifications for coding discharge data including the most complicated encounters/cases.
- Assigns Codes:
- Codes all diagnostic and operative information from the medical record using ICD-10-CM, CPT and HCPCS coding classification systems and independently quality checks own work.
- Selects the DRG for each inpatient case.
- Optimizes hospital payment legitimately and ethically by utilizing approved coding guidelines and conventions.
- Reviews DRG discrepancies from the fiscal intermediary to ensure the appropriate per case DRG assignment.
- Verifies and abstracts, all medical data from the record to complete a data abstract on each hospital encounter. Corrects data as appropriate.
- Ensures that all data abstracted is consistent with guidelines outlined by JCAHO, OSHPD and CMS, regional and local policy.
- Must have at least three (3) years hospital inpatient experience coding within the last five years. Demonstrated ability to understand the clinical content of a health record, including the most complicated records
- Must also be able to communicate with physicians in order to clarify diagnoses/procedures and sequencing of diagnoses.
- Ability to demonstrate knowledge of and utilize auditing skills related to coding quality and compliance
- Must be able to meet quantity and quality standards established for Coders II.
- Must be able to pass coding test .
- Basic PC skills.
- Must maintain a minimum of ten (10) CE units annually. Must maintain current coding credential.
- Will abide by the AHIMA coding code of ethics.
Physical and Mental Demands:
- Ability to sit for long periods of time.
- Ability to lift, push or pull 11 to 20 pounds. Occasional bending, stooping, kneeling, crouching, reaching.
- Ability to withstand the pressure of continual deadlines and receipt of work with variable requirements.
- Ability to concentrate and maintain accuracy in spite of frequent interruptions.
- Manual dexterity.
- Background knowledge analysis, assembly, terminal digit filing, and physician?s incomplete processing preferred.
Completion of Medical Records:
- Interacts with physicians to clarify and accurately document patient diagnostic and procedural information.
- Enters patient information into the computerized inpatient and outpatient medical record databases, ensuring the accuracy and integrity of the medical record abstract data prior to transmitting case to Government Reimbursement for billing.
- Ensures timely record availability by meeting established coding and abstracting productivity standards.
- Independently conducts medical record documentation auditing to monitor physician compliance with regulatory requirements i.e., Physician Review Project.
Confidentiality/Security of Systems:
- Maintains and complies with policies and procedures for confidentiality of all patient records.
- Demonstrates knowledge of security of systems by not sharing computer logons.
Corporate Compliance Accountability:
- Consistently supports the precepts of Corporate compliance and Principles of Responsibility by maintaining confidentiality, protecting the assets of the organization, acting with integrity, reporting observed fraud and abuse and complying with applicable state, federal and local laws and program policies and procedures.
- Answers the telephone promptly and identifies themselves and the department.
- Acts as an expert resource person to other coders and personnel in other hospital departments regarding coding questions and issues.
- Other duties as assigned by supervisors.
This position requires certification as a Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA).
- Completion of classes in medical terminology, anatomy and physiology, ICD-10 and CPT coding conventions, and disease process from an accredited program.
- Must have high school diploma or GED.