Description
Job Responsibilities:
Reviews medical record documentation and accurately assigns appropriate ICD-10 diagnoses and procedure codes leading to the assignment of the correct Medicare Severity-Diagnosis Related Group MS-DRG or All Patient Refined Diagnosis Related Group APR-DRG. The Inpatient Coding Specialist I is responsible for verification of the patient's discharge disposition assigning the correct sources of admission for state regulation reporting purposes and ensuring the appropriate present on admission POA indicators are assigned to each code. The assigned codes must support the reason for the visit that is documented by the provider in order to support the care provided.
Correctly abstracts required data per facility specifications.
Responsible for monitoring Discharged Not Billed accounts and as a team ensures timely compliant processing of inpatient accounts through the revenue cycle.
Collaborates with Clinical Documentation Specialists CDSs and members of the medical staff to ensure completeness of documentation in the medical records so that appropriate codes and ultimately the correct Diagnosis Related Group DRG may be assigned.
Responsible for ensuring accuracy and maintaining established quality and productivity standards.
Demonstrates a high degree of independence in performance of responsibilities working effectively without direct supervision. Exhibits strong time management problem solving and communication skills.
Possesses critical thinking good judgment and decision making skills
Demonstrates excellent written and oral communication skills
Remains abreast of current Centers for Medicare and Medicaid Services CMS requirements as well as Correct Coding Initiative CCI edits Hospital Acquired Conditions HACs Patient Safety Indicators PSIs and when applicable National Coverage Determinations NCDs and Local Coverage Determinations LCDs including the addition of appropriate modifiers to ensure a clean claim the first time through.
Maintains competency and accuracy while utilizing tools of the trade such as the 3M encoder 3M Audit Expert process 3M AES 3M Clinical Documentation Improvement System 3M CDIS and abstracting systems as well as all reference materials.
Attends required system hospital and departmental meetings and educational sessions as established by leadership as well as completion of required annual learning programs to ensure continued education and growth.
Employees must abide by all Joint Commission requirements including but not limited to sensitivity to cultural diversity patient care patients rights and ethical treatment safety and security of physical environments emergency management teamwork respect for others participation in ongoing education and training communication and adherence to safety and quality programs sustaining compliance with National Patient Safety Goals and licensure and health screenings.
Requirements
Our client is specifically looking for candidates who have:
5+ years of coding experience
completion of the Coder Proficiency Exam pre-hire
Ability to adapt to and deal with change and ambiguity
Ability to plan organize prioritize work independently and meet deadlines
Ability to comply with the American Health Information Management Associations Code of Ethics and Standards and apply Uniform Hospital Discharge Data Set UHDDS standards
Ability to establish and maintain effective working relationships
Ability to manage organize prioritize multi-task and adapt to changing priorities
Ability to solve technical and non-technical problems
Ability to utilize the ICD-10-CM/PCS and CPT-4 coding conventions to code medical record entries abstract information from medical records read medical record documentation assign accurate codes for grouping of MS-DRGs and APR-DRGs
Ability to work effectively through and with others
Knowledge of diagnosis/procedure DRG grouping schemes such as MS-DRGs and APR-DRGs
Knowledge of health information systems for computer application to medical records
Ability to foster effective working relationships and build consensus
Ability to work effectively with individuals at all levels of the organization
Knowledge of CCI Correct Coding Initiatives and CMS compliance issues
Knowledge of computer systems and software used in functional area
Knowledge of standards and regulations pertaining to the maintenance of patient medical records medical records coding systems medical terminology anatomy and physiology and study of diseases
High school diploma or GED required
Licenses and Certifications:
RHIA - Registered Health Information Administrator or
RHIT - Registered Health Information Technician or
CCS - Certified Coding Specialist
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