Overview
Coding Specialist Assign appropriate ICD codes to diagnoses and procedures for inpatient encounters. Perform the functions of concurrent reviews, concurrent coding, assembling and analyzing discharged patients' medical records. Update incomplete/deficient medical record reports as needed. Assist with the filing of patient medical record documentation.
Responsibilities
SUMMARY OF ESSENTIAL JOB FUNCTIONS
- Demonstrates and understands the importance of and respect for the rights, dignity and individuality of each patient in all interactions.
- Manages the daily operations of coding for assigned hospitals ensuring timely and accurate coding of medical records.
- Maintain a DRG accuracy rate of 95% and code accuracy of 95%.
- Must communicate documentation improvement needs with the medical staff in a query format, verbal and/or written.
- Will assign DRGs on admissions, concurrently code during the visit and final code within 5 calendar days of the patient discharge.
- Will assist with education for documentation improvement in conjunction with the Case Manager of the local facility.
- Accurately abstracts each medical record in accordance to best practice standards.
- Will assist in the patient evaluation process by providing a preliminary DRG.
- Will attend the weekly inter-discipline team meeting or its equivalent.
- Must have knowledge of medical terminology, the human disease process, anatomy and physiology.
- Must be able to demonstrate knowledge of ICD-10-CM and ICD-10-PCS.
- Must be able to demonstrate knowledge of reimbursement (Medicare) principles.
- Develop an understanding of responsibilities for participation in Performance Improvement activities.
- Participate in Care Conference meetings when needed.
- Understands work objectives, establishes priorities, anticipates and handles problems and carries out work activities in an orderly and timely manner to meet defined standards.
- Displays a positive/effective working relationship with co-workers, other department and medical staff. Demonstrate respect, friendliness and helpfulness in dealing with the public in person and/or over the telephone.
- Attend scheduled staff meetings
STANDARD JOB DUTIES
- Adheres to all components of the Hospital Compliance Plan in performing job duties and reports any violations or suspected violations of the Plan to the Compliance Officer.
- Demonstrates professional conduct and complies with hospital and departmental policies and procedures.
- Adheres to hospital attendance policy as outlined in the Employee Handbook.
- Complies with measures for preventing exposure to blood borne pathogens.
- Participates in the Hazardous Material Program; hazards include exposure to blood and body fluids, possible communicable diseases, sharp objects and instruments, assorted chemicals and gasses as listed in the Hazardous Materials Program Manual.
- Complies with established Safety and Patient Safety Program practices.
- Performs other incidental and related duties, as required and/or assigned.
- Develops an understanding of responsibilities for recognizing patient abuse and follows policy for making appropriate referrals/interventions.
- Develops an understanding of responsibilities for participation in Performance Improvement activities and participates in such activities.
- Limits access to protected health information (PHI) to the information reasonably necessary to do the job, and shares such information only on a need-to-know basis for work purposes.
(Access to verbal, written and electronic PHI for this job has been determined based on job level and job responsibility within the organization. Computerized access to PHI for this job has been determined as described above and is controlled via user ID and password.)
Qualifications
Qualifications:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions.
Education/Experience:
- Associate’s degree in Health Information Technology required.
- Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) preferred. American Health Information Management (AHIMA) Certified Coding Specialist (CCS) or American Academy of Professional Coder (AAPC) Certified Professional Coder (CPC) or Certified Professional Coder – Hospital (CPC-H) Coding Certification required.
- 2+ years of coding experience in an acute setting required, LTACH experience preferred.
Associate’s Degree. RHIT credentials or four years of inpatient coding experience, preferably in an LTAC environment.
Computer Skills:
Knowledge of basic computer skills and word processing.
Certificates and Licenses:
RHIT or equivalent preferred
Supervisory Responsibilities:
None
Work Environment:
The work environment is representative of that which an employee encounters while performing the essential functions of this job. The noise level in the work environment is usually moderate.
Physical Demands:
The physical demands of this job are representative of those that must be met by an employee to successfully perform the essential functions of the position. Reasonable accommodation may be made to a qualified individual with a disability who can perform the essential functions of this position with or without reasonable accommodation. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus while performing the duties of this job. The employee is regularly required to stand; walk; use hands to finger, handle, or feel; reach with hands and arms; talk; and hear.
SUMMARY OF ESSENTIAL JOB FUNCTIONS
- Demonstrates and understands the importance of and respect for the rights, dignity and individuality of each patient in all interactions.
- Manages the daily operations of coding for assigned hospitals ensuring timely and accurate coding of medical records.
- Maintain a DRG accuracy rate of 95% and code accuracy of 95%.
- Must communicate documentation improvement needs with the medical staff in a query format, verbal and/or written.
- Will assign DRGs on admissions, concurrently code during the visit and final code within 5 calendar days of the patient discharge.
- Will assist with education for documentation improvement in conjunction with the Case Manager of the local facility.
- Accurately abstracts each medical record in accordance to best practice standards.
- Will assist in the patient evaluation process by providing a preliminary DRG.
- Will attend the weekly inter-discipline team meeting or its equivalent.
- Must have knowledge of medical terminology, the human disease process, anatomy and physiology.
- Must be able to demonstrate knowledge of ICD-10-CM and ICD-10-PCS.
- Must be able to demonstrate knowledge of reimbursement (Medicare) principles.
- Develop an understanding of responsibilities for participation in Performance Improvement activities.
- Participate in Care Conference meetings when needed.
- Understands work objectives, establishes priorities, anticipates and handles problems and carries out work activities in an orderly and timely manner to meet defined standards.
- Displays a positive/effective working relationship with co-workers, other department and medical staff. Demonstrate respect, friendliness and helpfulness in dealing with the public in person and/or over the telephone.
- Attend scheduled staff meetings
STANDARD JOB DUTIES
- Adheres to all components of the Hospital Compliance Plan in performing job duties and reports any violations or suspected violations of the Plan to the Compliance Officer.
- Demonstrates professional conduct and complies with hospital and departmental policies and procedures.
- Adheres to hospital attendance policy as outlined in the Employee Handbook.
- Complies with measures for preventing exposure to blood borne pathogens.
- Participates in the Hazardous Material Program; hazards include exposure to blood and body fluids, possible communicable diseases, sharp objects and instruments, assorted chemicals and gasses as listed in the Hazardous Materials Program Manual.
- Complies with established Safety and Patient Safety Program practices.
- Performs other incidental and related duties, as required and/or assigned.
- Develops an understanding of responsibilities for recognizing patient abuse and follows policy for making appropriate referrals/interventions.
- Develops an understanding of responsibilities for participation in Performance Improvement activities and participates in such activities.
- Limits access to protected health information (PHI) to the information reasonably necessary to do the job, and shares such information only on a need-to-know basis for work purposes.
(Access to verbal, written and electronic PHI for this job has been determined based on job level and job responsibility within the organization. Computerized access to PHI for this job has been determined as described above and is controlled via user ID and password.)
Qualifications:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions.
Education/Experience:
- Associate’s degree in Health Information Technology required.
- Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) preferred. American Health Information Management (AHIMA) Certified Coding Specialist (CCS) or American Academy of Professional Coder (AAPC) Certified Professional Coder (CPC) or Certified Professional Coder – Hospital (CPC-H) Coding Certification required.
- 2+ years of coding experience in an acute setting required, LTACH experience preferred.
Associate’s Degree. RHIT credentials or four years of inpatient coding experience, preferably in an LTAC environment.
Computer Skills:
Knowledge of basic computer skills and word processing.
Certificates and Licenses:
RHIT or equivalent preferred
Supervisory Responsibilities:
None
Work Environment:
The work environment is representative of that which an employee encounters while performing the essential functions of this job. The noise level in the work environment is usually moderate.
Physical Demands:
The physical demands of this job are representative of those that must be met by an employee to successfully perform the essential functions of the position. Reasonable accommodation may be made to a qualified individual with a disability who can perform the essential functions of this position with or without reasonable accommodation. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus while performing the duties of this job. The employee is regularly required to stand; walk; use hands to finger, handle, or feel; reach with hands and arms; talk; and hear.
