Job Description

To be considered for this position, candidates must reside in either the State of Washington or the State of Oregon.

Job Summary :

To independently and efficiently perform the responsibilities of assigning accurate diagnosis and procedure codes to the patient's health information records for the Emergency Department (ED), Ambulatory Surgical Center (ASC), Hospital Ambulatory Surgical Center (HAS), Observations (OBS), Inpatient (IP) and other selected facility records. Maintain an acceptable level of performance in quality and productivity for ICD-10-CM, ICD-10-PCS, and HCPCS/CPT classification and nomenclature systems. All work will be carried out in accordance with the International Classification of Diseases - Official Coding Guidelines for coding and reporting as established by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS); American Medical Association (CPT); National Correct Coding Initiative (NCCI); Uniform Hospital Discharge Data Set (UHDDS), Medicaid (OMAP), and the Company's organization/institutional coding directives. Ability to communicate with physicians in order to obtain clarification for diagnoses/procedures. Ability to understand the clinical content of the health record, abstract the data in the patient health information record data, and perform other duties assigned. The position requires the new coder to be onsite for one (1) week of training or until they meet the department's expectations.

Essential Responsibilities : 

• Proficient in medical record review and translating clinical information into coded data. Identify and assign appropriate codes for diagnoses, procedures, and other services rendered while also validating any Computer Assisted Coded (CAC) assignments for dual coding and utilizing the Code Base Charge Trigger system (CBCT) and OPTUM 360 EncoderPRO software system for professional surgical services, analyzing and maintaining systems accuracy, validity, and meaningfulness for both professional and facility services. Utilizes electronic patient data and clinical information systems (EpicCare) to access patient encounter information. Abstracts and enters clinical data elements as defined by the organization's needs. Identifies and assigns principal diagnosis and procedure codes, sequencing them as needed for proper Ambulatory Payment Classification (APC), Medicare Severity-Drug Related Group (MS-DRG), All Patients Refined Diagnosis Related Groups (APR-DRG) assignment, utilizing applicable coding conventions. Demonstrates knowledge and understanding of CMS HCC Risk Adjustment coding - Routinely performs chart analysis to identify areas of the medical record that contain incomplete, inaccurate, or inconsistent documentation. Reviews and verifies chart information (i.e., POS, attending provider). Assesses and inputs data. Reviews and verifies component parts of medical records to ensure completeness and accuracy of diagnostic and therapeutic procedures that must conform to CMS coding rules and guidelines. Meets and maintains department standards 95% for productivity and quality - Coding Auditor Senior spends at least 80% of work time assigning codes to Inpatient records.
• Fully utilizes resources available, such as Coding Clinic and CPT Assistant, to research issues and apply coding guidelines. Identifies coding concerns and informs supervisors and managers as appropriate. Utilizes query process when applicable. Assists in implementing solutions to reduce back-end coding errors. Stay current on coding and regulatory publications and attend workshops to stay abreast of current issues, trends, and changes in the laws and regulations governing medical record coding and documentation to mitigate the risk of fraud and abuse and to optimize revenue recovery.
• May assist with special projects. Maintain confidentiality and effective working relationships with staff. Communicate clearly and understandably and exercise independent judgment. Reviews annual ICD-10 Official Guidelines for Coding, along with a review of quarterly Coding Clinic and monthly CPT Assistant - Performs as a team member of Facility Coding Services and actively participates with peers coding in-services, staff meetings, reporting of performance measures, and quality outcome monitors. May participate in the development of organizational procedures. Attends and participates in selected national and regional coding education sessions. Perform other duties as assigned.

Qualifications :

Basic Qualifications :

Experience :

• Minimum five (5) years' experience in coding with four (4) years inpatient facility coding
• Must reside in the State of Washington or the State of Oregon

Education :

• A High School Diploma or General Education Development (GED) is required.

License, Certification, Registration :

The candidate must have 1 from the following list :

• Registered Health Information Technician Certificate
• Coding Specialist Certificate
• Registered Health Information Administrator Certificate

Additional Requirements :

• Previous experience with EMR patient documentation systems with intermediate knowledge and skill in the use of a computer
• Advanced knowledge of disease processes, diagnostic and surgical procedures, Inpatient ICD-10-CM, ICD-10-PCS, HCPCS/CPT classification systems, health information/medical record department responsibilities with knowledge of government regulations and areas of scrutiny for potential fraud and abuse issues.
• Advanced knowledge of medical terminology, pharmacology, and medial coding principles for ICD-10-CM, ICD-10-PCS, HCPCS/CPT, and coding.
• Fluent in English, demonstrating skill and proficiency in oral and written communication.
• Skills in time management, organization, and analytical skills
• Ability to manage a significant workload and work efficiently under pressure, meeting established deadlines with minimal supervision
• Ability to use independent thought and judgment
• Abides by the Standards of Ethical Coding as set by the American Health Information Management Association (AHIMA).
• Meets and maintains department standards for performance, productivity, and quality
• The department will furnish the final candidate with a coding skill test. The candidate must pass with 75% or better on the test.
• Academic knowledge and working experience performing coding and abstracting responsibilities in health information/medical record services.

Preferred Qualifications :

• Minimum of five (5) years of experience in health information/medical record environment, with facility coding experience that includes Medicare reimbursement guidelines
• Degree in Health Information Management.
• Proficient knowledge and skill in using a computer and related system and software, including EMR(s), Microsoft Office Suite, and other software programs
• Ability to evaluate, analyze, and develop information regarding mathematical statistics and percentages that compare finding trends and outcomes related to productivity and /or medical record audits.
• Extensive knowledge of ICD-10 coding guidelines, with knowledge and demonstrated understanding of CMS HCC Risk Adjustment coding and data validation requirements.

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