Coder In-patient Level III

AtlantiCare•Egg Harbor Township, NJ

13d•Onsite

About The Position

The role of the Coder Inpatient Level III is to interact extensively with the physician and others members of the health care team to facilitate the improvement in the overall quality, completeness and accuracy of medical record documentation. This will support the appropriate clinical picture and level of severity of the patient while providing accurate and complete information that is utilized in the medical record and core measure abstraction and coding process to obtain appropriate reimbursement. This position will also be responsible for coordinating and providing education to all physicians and other clinicians related to compliant documentation responsibilities and coding and abstraction issues. This position will identify opportunities for documentation improvement to ensure accuracy and completeness of documentation used for measuring and reporting physician and hospital outcomes (e.g. patient safety indicators (PSI) and hospital acquired conditions (HAC). The Coder Inpatient Level III will collaborate as necessary with other disciplines as necessary to communicate these opportunities for referral to the appropriate performance improvement committee for resolution. This position will primarily review inpatient medical records using nationally recognized guidelines assure accurate and complete documentation of diagnoses and procedures and DRG assignment. The Coder Inpatient Level III will demonstrate understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix index, MS-DRG, APR-DRG, secondary diagnosis, and risk-adjustment methodologies, and impact of procedures on the final DRG .

Requirements

High School diploma required.
Certified Coding Specialist (CCS) required.
Minimum 5 years inpatient acute care coding (recent hands on production) experience required.

Nice To Haves

Associate of Science Degree in Health Information Technology preferred.
RHIA preferred.
Successful completion of a college based coding program or college based coding certificate program preferred (AHIMA-approved preferred).
Knowledge of Core Measures, HAC, and AHRQ PSI/Harm Measures preferred.
Proficiency in Clinical and Business Applications preferred at time of hire; incumbents within position will be trained appropriately and then skill will be required for this position within 30-60 days from date of hire.

Responsibilities

Interact extensively with the physician and others members of the health care team to facilitate the improvement in the overall quality, completeness and accuracy of medical record documentation.
Support the appropriate clinical picture and level of severity of the patient while providing accurate and complete information that is utilized in the medical record and core measure abstraction and coding process to obtain appropriate reimbursement.
Coordinate and provide education to all physicians and other clinicians related to compliant documentation responsibilities and coding and abstraction issues.
Identify opportunities for documentation improvement to ensure accuracy and completeness of documentation used for measuring and reporting physician and hospital outcomes (e.g. patient safety indicators (PSI) and hospital acquired conditions (HAC).
Collaborate as necessary with other disciplines as necessary to communicate these opportunities for referral to the appropriate performance improvement committee for resolution.
Primarily review inpatient medical records using nationally recognized guidelines assure accurate and complete documentation of diagnoses and procedures and DRG assignment.
Demonstrate understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix index, MS-DRG, APR-DRG, secondary diagnosis, and risk-adjustment methodologies, and impact of procedures on the final DRG .