Sr Coding Specialist TC

Summary:
Under the general supervision of the Health Information Coding Manager reviews the inpatient clinical documentation to extract data and assign appropriate codes in accordance with the inpatient ICD-9-CM Official Guidelines for Coding and Reporting. Determines appropriate MS assignment for optimal classification and accurate and compliant clinical reporting. Identifies and recommends physician queries when documentation in the chart is incomplete ambiguous or unclear. Maintains and meets HIS quality and productivity standards.

 

Responsibilities:
Reads the medical record identifying all treated diagnoses and procedures reporting the correct code(s) adhering to rules set forth in �Official Coding Guidelines.� Ensures the medical record documentation supports the codes selected for the principal diagnosis secondary diagnoses complications co-morbid conditions procedures and discharge disposition. Abides by the �Standards of Ethical Coding� as set forth by the American Health Information Management Association. Understands clinical documentation to recognize when a query to the physician is required.



For inpatient coding enters coded/abstracted information into the 3M DRG grouper assigning the accurate MS-DRG or APR-DRG through use of the clinical analyzing functions reviewed in compliance with medical record documentation. Adds Present On Admission (POA) indicator to diagnoses. Selects the physician performing procedures ensuring accuracy in the hospital�s billing system. Updates Clinical Documentation monitor. Sends accounts to the coding validation software program upon which validator reviews selected cases. Prioritizes high paying records to be completed the day received. May perform concurrent coding for in-house patients requiring interim billing. Continually meets coding productivity quality and accuracy standards.



Follows-up on all bill holds to ensure timely billing and reimbursement. Acts as a resource to physicians and other staff on coding principals and DRG assignments and/or outpatient coding issues.



Refers coding billing and system questions to the coding supervisor or coding validator. Seeks supervisory assistance only after exhausting own resources by referencing appropriate coding publications and manuals. Assists other coders with help answering questions and providing guidance to entry-level coders.



Keeps abreast of coding guidelines and reimbursement reporting requirements. Maintains credentials.



Maintains health information confidentiality by adhering to established organizational and departmental policies and procedures.



Performs related clerical and other duties as assigned.

 

Other information:
BASIC KNOWLEDGE:

Associate degree in health information technology (preferably with RHIT ) and/or successful completion of coding certification program



Coding certification required from the American Health Information Management Association (AHIMA (preferred) [RHIA RHIT CCA CCS or CCS-P] or the American Academy of Professional Coders (AAPC) [CPC or CPC-H].



Familiarity and understanding of the content of the medical record.



Trained in medical terminology medical science disease processes anatomy and physiology.



Ability to recognize and understand clinical documentation pertinent for coding.



Good writing skills to prepare compliant physician queries.



Computer literate; capable of research internet websites to clarify diseases or procedures.



Ability to navigate the patient electronic medical record to access and recognize appropriate data applicable to coding process.



EXPERIENCE:

Three to five years coding experience in a teaching or acute care hospital required with proven ability to understand the clinical content of a health record.



Reads medical records for the entire workday.



Ability to lift a minimum of 25 pounds bend stoop stretch use step-stools to file records.



Ability to work under stressful conditions to maintain accounts receivable days achieving productivity and accuracy.



After orientation at the hospital�s facilities work is performed at the employee�s residence in accordance with provisions of a telecommuting work agreement to which the employee has agreed as a condition of working in an off-campus location.



The hospital�s normal office and central work location environment applies for assignments meetings and other requirements as determined by department management.

 

Lifespan is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race color religion sex national origin age ethnicity sexual orientation ancestry genetics gender identity or expression disability protected veteran or marital status.   Lifespan is a VEVRAA Federal Contractor.

 

Location: Rhode Island Hospital USA:RI:Providence

 

Work Type: Per Diem

 

Shift: 1

 

Union: Non-Union


Work Schedule M-F 8 AM -4:30 PM