Clinical Coding Specialist I-Cape Fear Valley Urology, Full Time Days

Cape Fear Valley Health

1d

About The Position

Reviews thoroughly the entire medical record to code specifically and accurately those conditions or diagnoses that were treated or affected the patient's plan of care. Verifies that each medical record contains appropriate documentation to justify the selected principal diagnosis to identify comorbid conditions, complications and procedures to use for DRG Assignment. Maintains an accurate case mix index from which administration makes critical management and strategic planning decisions. The following is a summary of the major essential functions of this job. The incumbent may perform other duties, both major and minor, that are not mentioned below. In addition, specific functions may change from time to time: Codes all diagnoses, treatments, and procedures according to the appropriate classification system for that category of patient encounter Performs medical record abstracting of hospital admissions for reimbursement and statistical reporting Verifies patient data while abstracting for accuracy and completeness of patient database Refers to the Local Medical Review Policies, National Determination Coverage Policies and Local Determination Coverage Policies, as necessary, to ensure compliance with federal guidelines Assesses OCE, NCCI and CCI edits, as necessary, to apply appropriate modifiers and make appropriate referrals to revenue departments, claim billers, senior coders and other hospital contacts for accurate claim submission With full understanding of PPS regulations, the DRG classification systems (MS-DRG and APR-DRG), and CMS Patient Safety and Quality initiatives, communicates with physicians regarding the accuracy of principal and secondary diagnoses on the final code set, based on lab and other diagnostic findings, when the record may be subjected to QIO review due to vague attestation/documentation Other duties as assigned

Requirements

• High school diploma or equivalent required
• Applicants without Associate degree requires 2 years of ICD-CM/CPT-4 coding experience
• Good data entry skills
• Familiarity with medical record content and understanding of ICD-CM/CPT4 coding principals
• Ability to assign accurate codes using good judgement within broad guidelines
• Flexible and capable of intense concentration in a busy, noisy and crowded environment
• Near visual acuity
• Motor coordination to operate computer
• Most work is sedentary

Nice To Haves

• Associates degree preferred

Responsibilities

• Codes all diagnoses, treatments, and procedures according to the appropriate classification system for that category of patient encounter
• Performs medical record abstracting of hospital admissions for reimbursement and statistical reporting
• Verifies patient data while abstracting for accuracy and completeness of patient database
• Refers to the Local Medical Review Policies, National Determination Coverage Policies and Local Determination Coverage Policies, as necessary, to ensure compliance with federal guidelines
• Assesses OCE, NCCI and CCI edits, as necessary, to apply appropriate modifiers and make appropriate referrals to revenue departments, claim billers, senior coders and other hospital contacts for accurate claim submission
• With full understanding of PPS regulations, the DRG classification systems (MS-DRG and APR-DRG), and CMS Patient Safety and Quality initiatives, communicates with physicians regarding the accuracy of principal and secondary diagnoses on the final code set, based on lab and other diagnostic findings, when the record may be subjected to QIO review due to vague attestation/documentation
• Other duties as assigned

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED
• Number of Employees: 5,001-10,000 employees