Coders II differ from Coders I in the type & amountt of supervision received; responsibility for data comprehensiveness & quality assurance; data analysis, knowledge of procedures related to the sequencing of diagnoses & interventions, data mgmt policies & procedures; req'd quantity & quality perf standards.
Essential Functions:
- Reviews medical records to identify diagnoses/procedures
- Selects the DRG for each inpatient case
- Reviews DRG discrepancies from the fiscal intermediary to ensure appropriate DRG assignment/case
- Verifies all medical data from the record to complete a data abstract on each hosp encounter
- Ensures that all data abstracted/coded are consistent w/ guidelines outlined by The Joint Commission, OSHPD, CMS, regional/local policy
- Enters patient info into computerized med record databases; ensures accuracy & integrity of the medical record abstract/encounter data prior to transmitting case to Government Reimbursement
- Ensures timely record availability by meeting est. coding & abstracting productivity/quality standards
- Maintains & complies w/ policies & procedures for confidentiality of all patient records
- Other duties as assigned
- HIM CODER I - ADDITIONAL ESSENTIAL DUTIES: Under gen supervision, organizes/prioritizes all work to ensure records are coded in timeframes that comply w/ regulations
- Knowledge of all procedures concerning sequencing of diagnoses, procedures in but not limited to ICD-9-CM, CPT, Uniform Hospital Discharge Data Set, Medicare guidelines & other approp. classification systems
- Interacts w/ physicians to clarify/accurately document patient diagnostic & procedural info
- Knowledge of anatomy/physiology to interpret medical classifications for coding outpatient encounter/inpatient discharge data
- Under dir supervision, codes all diagnostic & operative info from medical record using ICD-9-CM, CPT, HCPCS level 2 coding classif. systems
- Participates in med record documentation auditing to monitor physician compliance w/ regulations
- Acts as a resource to hospital depts on coding questions/issues
- HIM CODER II - ADDITIONAL ESSENTIAL DUTIES: Organizes/prioritizes work to ensure records are coded in timeframes that comply w/ regulations
- Expert-level knowledge of all procedures concerning sequencing of diagnoses/procedures including those outlined in ICD-9-CM, CPT, Uniform Hosp Discharge Data Set, Medicare guidelines & other approp classification systems
- Knowledge of anatomy/physiology to interpret general med classifications for discharge data including the most complicated encounters/cases
- Codes all diagnostic & operative info from medical record using ICD-9-CM, CPT & HCPCS coding classif systems. Quality checks own work
- Optimizes hosp payment legitimately & ethically by using approved coding guidelines & conventions
- Interacts w/ physicians to clarify & accurately document patient diagnostic & procedural info
- Independently conducts med record documentation auditing to monitor physician compliance w/ regulations
- Acts as expert resource to coders & other hosp depts on coding questions/issues
- This position has no supervisory responsibilities. Coder II's may provide guidance & assistance to coders
The above duty statements are intended to describe the general nature & level of work being performed by individuals assigned to positions in this classification, they are not intended to be construed as an exhaustive list of duties, responsibilities & skills required of every position so classified
Qualifications:
Basic Qualifications:
HIM CODER I
- Requires 2+ yrs of continuous hospital experience in coding/abstracting within the last 5 yrs
- Requires Certified Coding Associate (CCA) & eligibility to become a Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA)
- Demonstrated ability to understand the clinical content of a health record
HIM CODER II
- Requires 3+ yrs of hospital inpatient experience coding within the last 5 yrs
- Requires certification as a Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA)
- Demonstrated ability to understand the clinical content of a health record, including the most complicated records
- Ability to demonstrate knowledge of & utilize auditing skills related to coding quality & compliance
- Background knowledge of analysis, assembly, terminal digit filing, & physician's incomplete processing preferred
HIM CODER I/II - ADDITIONAL QUALIFICATIONS:
- High School Diploma/GED
- Completion of classes in medical terminology, anatomy, physiology, ICD-9 & CPT coding conventions, & disease process from an accredited program
- Must be able to communicate w/ physicians to clarify diagnoses, procedures, & sequencing of diagnoses
- Basic PC skills
- Requires 75% on the Kaiser coding test
- Must be able to meet established quantity & quality standards
- Must maintain current coding credential & a minimum of 10 CEUs annually
- Must abide by the AHIMA coding code of ethics
- Must be willing to work in a Labor Management Partnership environment
- Additional qualifications may be outlined in the appropriate collective bargaining agreement
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.