Him Coder II PD

Description

Codes and abstracts conditions, diseases, reason for encounters, social determinants of health and outpatient procedures to report accurate administrative and clinical data, utilizing approved coding guidelines as set forth in Official Coding Guidelines, ICD Book, Coding Clinic for ICD-CM/PCS, AHA Coding Clinic for HCPCS and CPT Book.

Responsibilities

This is not an exhaustive statement of duties, responsibilities, or requirements. Employees will be required to perform any job, with related instruction given by their supervisor, subject to reasonable accommodation.

Codes and abstracts diseases, procedures from the medical record according to ICD-CM and CPT classification systems, utilizing only recognized coding guidelines. Abstracts data elements for state regulatory agencies as needed. (45%)

Validates coding to assure proper APC assignment . (30%)

Participates in quality improvement activities by identifying specific cases and pertinent data as requested. Completes and monitors follow up activities, complete documentation, MD Query responses, claim and DNB edits, daily. Participates and keeps abreast of coding education changes and participates in educational growth opportunities as well as maintain CEUs for certification. (10%)

Communicates with physicians concerning incomplete documentation and clarification of diagnoses/procedures utilizing appropriate facility query process. Communicates with Patient Financial Services regarding denials, rejections and appeals. (10%)

Participates in quality improvement activities by identifying specific cases and pertinent data as requested. (5%)

Communicates with physicians concerning incomplete documentation and clarification of diagnoses/procedures utilizing appropriate facility query process. (5%)

Qualifications

All job qualifications listed indicate the minimum level necessary to perform this job proficiently.

LEVEL OF EDUCATION

Minimum:

Formalized education that provides knowledge and experience in the following areas: 1) Assigning ICD-CM and CPT coding classifications in an acute care setting; 2) UHDDS reporting requirements; 3) Medical terminology, anatomy, chemistry, pharmacology, physiology, and disease process

Preferred:

Associates Degree Health Information Management

CERTIFICATIONS, LICENSES, REGISTRATIONS

Minimum:

CCS

Preferred:

CCS and RHIT or RHIA

TECHNICAL REQUIREMENTS

Preferred:

KNOWLEDGE, SKILLS, and ABILITIES

All knowledge, skills, and abilities listed indicate the minimum level deemed necessary to perform this job proficiently.

This position works with members of the Medical Staff and must be able to diplomatically deal with issues that arise when working with providers to clarify or obtain information necessary for accurate coding.

This position requires high level communication skills to be able to explain documentation variances as they relate to coding requirements.

Ability to work with minimum supervision and interact professionally with physicians and other hospital personnel. This position requires the following abilities: critical thinking skills to identify and locate information maintained in various mediums and locations, ability to read, understand, and reiterate clinical information to apply regulatory and coding standards for a multitude of acute care settings.