Clinical Documentation Coding Specialist III

University of Utah Health • Salt Lake City, UT

1d • Onsite

About The Position

This position provides inpatient facility coding and Clinical Documentation Improvement (CDI) support in the Health Information Management department. The incumbent must abide by hospital, state, and federal coding guidelines established by DNV, the American Hospital Coding Association, and Medicare/Medicaid, etc. The University of Utah is a Level 1 Trauma Center and is nationally ranked and recognized for its academic research, quality standards, and overall patient experience. Our five hospitals and eleven clinics provide excellence in our comprehensive services, medical advancement, and overall patient outcomes.

Requirements

• Proficient knowledge of medical terminology, anatomy & physiology and pathophysiology.
• Proficient knowledge of coding conventions & use of coding nomenclature.
• Proficient in all service lines of varying complexity.
• Working knowledge of health care quality related initiatives.
• Knowledge of healthcare IT systems, preferably Epic and 3M 360 Encompass R2.
• Knowledge of Microsoft Office.
• Team player, ability to collaborate with colleagues and leadership.
• Minimum of four (4) years of experience coding inpatient facility (HB).
• Current CCS Certification with the American Health Information Management Association (AHIMA).
• Current RHIT Certification with the American Health Information Management Association (AHIMA).
• Current RHIA Certification with the American Health Information Management Association (AHIMA).
• Additional license requirements as determined by the hiring department.

Nice To Haves

• Experience at Level 1 Trauma facility coding inpatient HB.
• Bachelor's or Associate's degree in a related field.

Responsibilities

• Perform thorough review of medical record for identification of relevant clinical diagnoses and procedures performed.
• Assign appropriate ICD-CM principal diagnosis code.
• Assign appropriate ICD-CM secondary diagnosis codes.
• Assign appropriate ICD-10 PCS code(s).
• Sequence principal and secondary diagnoses codes and primary procedure code for accurate MS-DRG and APR-DRG assignment.
• Assign Present on Admission (POA) indicator for each diagnosis code.
• Abstract required data elements, including but not limited to: Admit Type, Admit Source / Point of Origin, and Discharge Disposition.
• Identification of opportunities where additional provider documentation is required to thoroughly and accurately assign ICD-10 code.
• Understand and adhere to compliant provider query practices and procedures.
• Understand and adhere to Health Information Coding policies and Official Coding Guidelines, as published by CMS and Cooperating Parties.
• Achieve and sustain acceptable productivity rate as defined by Coding Leadership.
• Ability to effectively communicate with clinical staff and other hospital department personnel.
• Ability to effectively mentor entry-level staff.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree