Inpatient Coder
Description:
*This position is remote, and the candidate must reside in Pennsylvania or New Jersey*
JOB SUMMARY
Reviews patient records, assigns diagnostic and procedural codes, performs related functions and participates in Performance Improvement activities.
ESSENTIAL FUNCTIONS
DIAGNOSTIC CODING OF ALL MEDICAL RECORDS REPORTED ON PATIENT BILLS
By coding all diagnoses, treatments, and procedures according to the appropriate classification system for the category of patient encounter
By accurately coding all inpatient records in accordance with ICD-10 CM/PCS coding rules and guidelines in a timely manner with a 95% accuracy rate
By following approved coding conventions, assigns diagnostic and procedural codes to inpatient records
Reviews AHA Coding Clinic and demonstrates the ability to accurately apply new coding guidelines.
Researches new diagnostic and procedure codes as required performing the coding function.
Informs coding supervisor of trends and opportunities for improvement in clinical documentation.
Works collaboratively with other coders.
Adheres to the American Health Information Management’s Code of Ethics.
LOCATES MEDICAL RECORDS THAT REQUIRE CODE ASSIGNMENT
By searching master patient index; identifying location of existing patient records and obtaining the documentation required for code assignment.
MAINTAINS MEDICAL RECORDS OPERATIONS
By following policies and procedures; reporting needed change
RESOLVES MEDICAL RECORD DISCREPANCIES
By acting as a resource to other staff on coding issues
By assisting the physicians with documentation improvement via the diagnostic query form
By collecting and analyzing information
MAINTAINS HISTORICAL REFERENCE
By abstraction and data entry of all inpatient records into the Good Shepherd Hospital computer system for clinical and financial purposes
By abstracting and coding clinical data, such as diseases, procedures, using standard classification systems.
By providing DRG/CMG forecasting information to Nurse Liaison as needed.
By accurately assigning the correct principal diagnosis on LTCH and rehab accounts.
By performing weekly/bi-weekly concurrent chart reviews for any potential DRG/CMG changes during the patient stay.
By coding all discharged charts timely and accurately
PROVIDES MEDICAL RECORD INFORMATION
By providing codes for billing and answers questions from hospital staff
By assisting physicians and other direct patient care professionals in questions regarding level of detail for diagnostic entries, according to the organization’s guidelines
MAINTAINS THE STABILITY AND REPUTATION OF THE HOSPITAL
By complying with legal requirements.
QUALIFICATIONS:
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, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education
High School Diploma required
Completion of the AHIMA independent study program preferred
Work Experience
2-4 years of inpatient coding experience utilizing ICD-9-CM and/or ICD-10-CM/PCS required
Licenses / Certifications
RHIA, RHIT, CCS, CPC, active member in AHIMA preferred