Health Info Coder II

Job Posting

Our Mission is to provide excellent healthcare services by highly skilled staff in a compassionate and caring manner. We know that our employees are essential to the care we provide!

Our core values are as follows: Courtesy, Respect, Caring, Professionalism, Confidentiality, Integrity, and Accountability.

Educational Requirements and Qualifications:

• High School diploma/GED or relevant experience is required.
• Formal education in anatomy and physiology, medical terminology, disease processes, content of a medical record, coding of diagnoses using ICD-10-CM and procedures using ICD-10PCS and Current Procedural Terminology (CPT) required.
• Minimum of 10+ years' experience in a healthcare environment is required with current experience with inpatient, observation, and surgery coding.
• One or more of the following credentials are required: RHIA, RHIT, CCS
• Additional preferred but not required CPC, COC
• Demonstrate ability to communicate and work in a professional manner with members of the medical staff, government agencies, and third party payers.
• Knowledge and ability to read, interpret and follow hospital and government rules and regulations relating to but not limited to safety, privacy, security, procedural manuals and official coding guidelines.
• Ability to communicate effectively and professionally with internal and external customers and co-workers.
• Demonstrate knowledge and skill in computerized data entry and retrieval systems.
• Willingness to continue education on coding, guidelines and CMS, WPS, and HFAP guidelines and/or standards.
• Ability to aggregate data and ensure data integrity by analyzing reports built in the EMR and EHR.
• Ability to build ad hoc reports. Then transition data into useable information for trending the financial impact to the organization.

Primary Duties:

• Contacts appropriate medical staff members and makes queries to rectify inconsistencies, deficiencies, and discrepancies in medical record documentation.
• Reviews the medical record for continuing quality improvement activities, performs quality improvement activities in support of hospital-wide medical documentation concerns. Performs clinical pertinence review on randomly selected medical records against specified criteria, as requested.
• Calculate the impact of record reviews and present it to necessary committees at the discretion of the Director.
• Educate staff/physicians on inadequate or missing documentation according to ACHC standards.
• Query providers for any documentation discrepancies and medically necessary procedures when needed.
• Reviews and analyzes, abstracts, and codes outpatient and/or inpatient medical records, assigns diagnoses and procedure codes, and provides assistance to the professional staff. Demonstrates knowledge of outpatient and inpatient coding guidelines, including E & M level coding, accreditation references and medical terminology, anatomy and physiology.
• Codes disease and injury diagnoses, acuity of care, and procedures in a wide range of outpatient and inpatient settings and specialties using the current International Classification of Diseases, Version 10- Clinical Modification ICD-10-CM/ICD-10-PCS; American Medical Association Current Procedural Terminology (CPT); Health Care Financing Administration Common Procedure (HCPCS) Coding System.
• Selects the appropriate code(s) and/or modifier(s) that most accurately describe the correct principal and secondary diagnoses and principal and secondary procedures, based on physician clinical documentation.
• Bases all coding on what the physician documents in the medical record. Including outpatient physician orders for outpatient services such as radiologist and pathologist reports.
• Inputs the codes and other discharge data into Electronic Health Record and verifies the accuracy of data entered including charges on outpatient accounts. Performs qualitative analysis to ensure accuracy, internal consistency, and correlation of recorded data.
• Selects and inputs charge codes, in Electronic Health Record, for facility and professional billing.

Shift: Monday-Friday; Days; 7:00am-3:30pm OR 8:00am-4:30pm

Benefits:

• Medical
• Dental
• Vision
• Life Insurance & Disability
• 403(b) with match
• Paid Vacation Time
• Paid Sick Time
• FSA